RUSSELL    SAGE 
FOUNDATION 


•  MEDICAL  INSPECTION 
OF  SCHOOLS , 


BY 


T 


LUTHER  HALSEY  GULICK,  M.D. 

AND 
LEONARD  P.  AYRES,  PH.D. 


NEW     YORK 

SURVEY     ASSOCIATES,     INC. 
MCM  X  I  I  I 


Copyright,  1913,  by 
THE  RUSSELL  SAGE  FOUNDATION 

Printed  October,  1908 

Reprinted  January,  1909 

Reprinted  December,  1909 

Revised  and  reprinted,  January,  1913 


PRESS  OF  WM.   F.   FELL  CO. 
PHILADELPHIA 


PREFACE 

THIS  volume  is  a  revision  of  Medical  Inspection  of  Schools, 
published  by  the   Russell  Sage  Foundation  in  October, 
1 908.     The  first  edition  was  exhausted  within  three  months, 
and  the  volume  was  reprinted  in  January,   1909,  and  again  in 
December  of  the  same  year.      During  the  three  and  a  half  years 
that  have  elapsed  since  the  first  publication  of  the  volume  there 
has  been  a  three-fold  increase  in  the  number  of  American  cities 
having  systems  of   medical  inspection  of  schools.      In  rapidity 
and  extent,  this  development  has  been  unequalled  by  that  of 
any  other  educational  movement  in  America. 

During  these  few  years  physical  examinations  have  become 
an  integral  part  of  all  the  more  important  systems  of  medical 
inspection.  The  school  nurse,  almost  unknown  four  years  ago, 
is  now  an  important  adjunct  of  the  systems  of  scores  of  cities. 
Dental  inspection,  then  in  its  infancy,  is  now  being  carried  on  in 
nearly  200  cities.  At  that  time  three  states  and  the  District 
of  Columbia  had  legal  provisions  for  medical  inspection.  Now 
the  number  has  increased  to  20. 

These  conditions  have  resulted  in  an  increasing  demand  for 
a  revision  of  the  original  text,  and  this  has  led  to  the  preparation 
of  the  present  volume.  While  covering  much  of  the  matter  treated 
in  the  original  book,  the  text  has  been  entirely  re-written,  and  the 
description  of  methods  and  forms,  as  well  as  the  quantitative 
material,  brought  down  to  date.  Like  its  predecessor,  this  book 
aims 

(i)  To  be  of  practical  use;  (2)  to  be  a  reliable  source  of 
information  as  to  what  is  now  being  done  and  how  it  is  being 
done;  (3)  to  be  frank  in  its  admission  of  problems  and  difficulties 
as  yet  unsolved;  (4)  to  avoid  all  dogmatism,  saving  that  involved 
in  the  statement  of  actual  experience. 

L.  H.  G. 
L.  P.  A. 
New  York,  January,  1913 


258679 


* 


SIGNIFICANT  FACTS 

'  <  T  T  T  E  endorse  legislation  providing  for  the  medical  inspec- 
\/\  /  tion  of  schools,  because  extended  and  varied  experi- 
V  V  ence  has  demonstrated  that  efficient  medical  inspec- 
tion betters  health  conditions  among  school  children,  safeguards 
them  from  disease,  renders  them  healthier,  happier  and  more  vig- 
orous, and  aims  to  insure  for  each  child  such  physical  and  mental 
vitality  as  will  best  enable  him  to  take  full  advantage  of  the 
free  education  offered  by  the  state/' — Extract  from  Resolutions 
Adopted  by  the  Conference  of  State  and  Provincial  Boards  of 
Health,  Los  Angeles,  June  3o-July  i,  1911. 

Medical  inspection  is  a  movement  national  in  scope  in 
England,  France,  Germany,  Norway,  Sweden,  Austria,  Switzer- 
land, Belgium,  Japan,  Australia  and  Tasmania.  It  is  found  in 
the  more  important  cities  in  Denmark,  Russia,  Bulgaria,  Egypt, 
Canada,  Mexico,  the  Argentine  Republic,  and  Chili.  In  the 
United  States  regularly  organized  systems  are  in  force  in  nearly 
one-half  of  the  cities,  while  a  beginning  has  been  made  in  nearly 
three-fourths  of  them. 

Medical  inspection  of  schools  had  its  inception  some  eighty 
years  ago,  and  during  the  past  quarter  of  a  century  it  has  assumed 
the  proportions  of  a  world-wide  movement.  It  is  found  in  all  the 
continents  and  the  extent  of  its  development  in  different  countries 
is  in  some  measure  proportionate  to  their  degree  of  educational 
enlightenment. 

Clear  distinction  must  be  made  between  medical  inspection, 
solely  for  the  detection  of  communicable  disease,  and  physical 
examinations  which  aim  to  discover  defects,  diseases,  and  physical 
abnormalities.  The  former  relates  primarily  to  the  immediate 
protection  of  the  community,  while  the  latter  looks  to  securing 
and  maintaining  the  health  and  vitality  of  the  individual. 

Medical  inspection  for  the  detection  of  contagious  diseases 
may  well  be  a  function  of  the  board  of  health,  for  it  aims  at  the 

vii 


MEDICAL    INSPECTION   OF    SCHOOLS 

protection  of  the  community.  Physical  examinations  for  the 
detection  of  non-contagious  defects  should  be  conducted  by  the 
educational  authorities,  or  at  least  with  their  full  cooperation, 
because  they  are  made  for  educational  purposes.  The  records 
of  physical  examinations  must  be  constantly  and  intimately 
connected  with  school  records  and  activities.  They  do  not  need 
to  be  connected  with  other  work  of  the  board  of  health. 

At  the  beginning  of  the  year  1912,  seven  states  had  man- 
datory laws  providing  for  medical  inspection,  10  had  permissive 
ones,  and  in  two  states  and  the  District  of  Columbia,  medical 
inspection  was  carried  on  under  regulations  promulgated  by  the 
state  boards  of  health  and  having  the  force  of  laws. 

Professor  William  Osier,  the  distinguished  English  physician, 
is  credited  with  saying  in  regard  to  the  work  of  medical  inspection 
in  England,  "  If  we  are  to  have  school  inspection,  let  us  have  good 
men  to  do  the  work  and  let  us  pay  them  well.  It  will  demand 
a  special  training  and  a  careful  technique/' 

The  school  nurse  is  the  most  important  adjunct  of  medical 
inspection.  She  is  the  teacher  of  the  parents,  the  pupils,  the 
teachers,  and  the  family,  in  applied  practical  hygiene.  She  is 
the  most  effective  possible  link  between  the  school  and  the  home. 

Dental  inspection  is  rapidly  becoming  one  of  the  most 
important  branches  of  medical  inspection.  First  in  Germany, 
next  in  England,  and  more  recently  in  the  United  States,  dental 
inspection  has  been  inaugurated  and  school  dental  clinics  estab- 
lished. The  work  is  now  being  carried  on  in  nearly  200  American 
cities. 

In  terms  of  financial  expenditure,  the  cheapest  sort  of 
medical  inspection  consists  of  examinations  conducted  by  teachers 
for  the  discovery  of  defects  of  vision  and  hearing.  These  involve 
only  the  added  expense  of  the  simple  printed  material  required. 
Inspection  by  physicians  for  the  detection  of  contagious  diseases 
costs  about  10  cents  per  child  per  year.  Systems  including  both 
inspections  for  contagious  diseases  and  examinations  to  detect 
physical  defects  cost  on  the  average  about  25  cents  per  child  per 
year.  Where  school  nurses  are  employed,  the  average  per  capita 

viii 


SIGNIFICANT   FACTS 

rate  is  about  30  cents  per  child  per  year,  and  this  may  probably 
be  regarded  as  a  minimum  cost  for  adequate  and  efficient  work. 

In  foreign  countries  complete  physical  examinations  are 
usually  conducted  only  two  or  three  times  in  the  course  of  the 
child's  school  career.  In  this  country  most  cities  attempt  to 
conduct  such  examinations  every  year  and  frequently  fall  far  short 
of  accomplishing  their  aim.  A  conservative  standard  efficiently 
maintained  is  better  than  a  high  ideal  that  is  never  reached. 

In  American  cities  having  relatively  efficient  systems  of 
medical  inspection,  the  number  of  defective  pupils  receiving 
remedial  treatment  as  a  result  of  the  examinations  ranges  from 
about  10  per  cent  to  about  50  per  cent.  In  England  the  work  is 
more  efficient  and  from  20  per  cent  to  70  per  cent  of  the  defective 
children  receive  remedial  treatment  from  physicians,  oculists,  or 
dentists. 

Medical  inspection  is  essential  in  country  districts  as  well 
as  in  large  cities,  and  in  rich  communities  as  well  as  in  poor  ones. 
The  locality  has  yet  to  be  discovered  in  which  the  medical  inspec- 
tion of  school  children  is  unnecessary  or  undesirable. 


IX 


TABLE  OF  CONTENTS 

PAGE 

PREFACE v 

SIGNIFICANT  FACTS vii 

LIST  OF  ILLUSTRATIONS xiii 

LIST  OF  TABLES xv 

LIST  OF  FORMS xix 

CHAPTER 

I.  The  Argument  for  Medical  Inspection  i 

II.  History  and  Present  Status 7 

III.  Inspection  for  the  Detection  of  Contagious  Diseases     .  21 

IV.  Physical  Examinations 35 

V.  The  School  Nurse 62 

VI.  Making  Medical  Inspection  Effective      .       .       .       .  72 

VII.  Results          .                             89 

VIII.  Per  Capita  Costs  and  Salaries 101 

IX.  Dental  Inspection 114 

X.  Controlling  Authorities  in  American  Municipalities       .  143 

XI.  Physical  Defects  and  School  Progress      .       .       .       .152 

XII.  Legal  Provisions 164 

APPENDICES 

I.  Suggestions  to  Teachers  and  School  Physicians  Regard- 
ing Medical  Inspection 183 

II.  Annual  Report  for  iQio/of  the  Chief  Medical  Officer 

of  the  British  Board  of  Education       .       .       .       .197 

BIBLIOGRAPHY 203 

INDEX 209 


XI 


LIST  OF   ILLUSTRATIONS 

Photographs  illustrating  work  in  the  New  York  schools  are  repro- 
duced by  permission  of  the  New  York  Child  Welfare  Committee.  Those 
referring  to  Orange,  N.  J.,  Rochester,  N.  Y.,  and  Toledo,  O.,  are  used  by 
permission  of  the  chief  medical  inspectors  and  school  authorities  of  those 
cities.  Grateful  acknowledgment  is  made  of  their  courtesy. 


FACING 
PAGE 


In  the  school  of  the  future  compulsory  education  will  involve 
compulsory  health Frontispiece 

Mouth  breathing  means  adenoids;   adenoids  mean  deadened 

intellects -4 

A  throat  culture  in  time  may  save  nine  weeks  of  diphtheria       .     1 2 
Vaccination  inspection  in  New  York  City 21 

Case  of  chicken-pox  discovered  in  a  class  room  in  New  York 

City   .  .     27 

Case  of  mumps  discovered  in  a  class  room  in  New  York  City    .     27 

No  exclusion  for  ringworm  when  cases  are  treated  by  the  nurse 
at  school 30 

First  aid  for  small  ailments  in  Toledo,  Ohio      ....     30 

Listening  for  trouble.  Testing  heart  and  lungs  in  New  York 
City 36 

Strong  boys  must  have  straight  backs       ...  .41 

Looking  for  obstructed  nasal  breathing  in  a  New  York  City 
school 41 

Vision  tests  by  physician  and  nurse  in  Orange,  N.  J.       .        .     46 

Testing  the  hearing  of  five  boys  at  one  time  in  a  New  York 
City  school.  Not  so  good  as  one  at  a  time,  but  sometimes 
necessary 53 

School  nurse  in  action; — first  aid  demonstration  in  Orange, 

N.J N    '      '  '    6? 

xiii 


LIST   OF    ILLUSTRATIONS 


FACING 
PAGE 


The  school  nurse  is  the  most  efficient  link  between  the  school 

and  the  home 67 

Team  work  between  physician  and  nurse  in  Toledo,  Ohio      .  76 

The  equipment  of  this  Rochester  dental  clinic  cost  about  $700  1 02 

Dental  treatment  costs  less  than  the  extra  schooling  bad  teeth 

involve 102 

Too  late  for  effective  treatment 114 

Each  missing  upper  tooth  renders  useless  the  corresponding 

lower  tooth 114 

Every  pupil  in  Rochester,  N.  Y.,  needing  dental  inspection 

receives  it 120 

Toothbrush  drill  in  New  York  City 120 

Persistently  neglected  teeth  become  mere  putrescent  stumps    .  1 29 

Reason  enough  for  retardation;  enlarged  tonsils  mean  lowered 

vitality 129 

Waiting  for  the  school  physician  in  Toledo,  Ohio        .       .       .148 
Throat  inspection  in  the  Orange,  N.J.,  schools    .       .       .       .148 

About  10  per  cent  of  the  school  children  of  our  cities  suffer 

from  malnutrition 155 

Typical  adenoid  faces  showing  mouth  breathing,  flattened 

noses,  and  protruding  eyes 1 70 


xiv 


LIST  OF  TABLES 

TABLE  PAGE 

1.  Cities  of  United  States  having  medical  inspection,  by  groups  of 

states.     1911 15 

2.  Cities  of  United  States  having  systems  of  medical  inspection  in 

each  year  from  189410 1911         .       .       .       .       .       .       .16 

3.  Cities  of  United  States  having  systems  of  medical  inspection, 

cities  employing  school  physicians,  and  number  of  physicians 
employed,  by  groups  of  states.     1911 17 

4.  Cities  of  United  States  having  systems  of  medical  inspection, 

cities  employing  school  nurses,  and  number  of  nurses  em- 
ployed, by  groups  of  states.     1911 18 

5.  Cities  of  United  States  having  systems  of  medical  inspection,  and 

cities  employing  school  dentists,  by  groups  of  states.     1911    .     19 

6.  Status  of  medical  inspection  in  1,046  municipal  school  systems  in 

the  United  States.     1911 20 

7.  Exclusions  for  contagious  diseases  in  four  cities        ....     32 

8.  Exclusions  for  contagious  diseases  in  four  cities: 

Relative  figures  on  the  basis  of  i  ,000  exclusions  in  each  city    .     33 

9.  School  membership,  exclusions  for  contagious  disease,  and  number 

of  exclusions  per  thousand  pupils  enrolled,  for  eight  cities       .     33 

10.  Cities  of  the  United  States  having  examinations  for  the  detection 

of  physical  defects,  by  groups  of  states.     1911          .       .       .36 

11.  Results  of  physical  examinations  of  schoolchildren  in  nine  cities    .     38 

12.  Results  of  physical  examinations  of  school  children  in  nine  cities: 

Relative  figures  on  basis  of  each  1,000  children  examined  in 
each  city 38 

13.  Results  of  physical  examinations  of  school  children,  New  York, 

N.  Y.,  191 1 40 

14.  Enrollment  in  day  schools  and  number  and  per  cent  of  pupils  ex- 

amined in  nine  cities      41 

15.  Vision  and  hearing  tests  conducted  by  physicians  and  teachers 

in  American  cities,  by  groups  of  states.     1911  .        .  51 

xv 


LIST  OF  TABLES 

TABLE  PAGE 

1 6.  Results  of  vision  and  hearing  tests  in  Massachusetts,  Connecticut, 

and  Maine 52 

17.  Results  obtained  by  medical  inspectors  aided  and  not  aided  by 

school  nurses.     Eight  schools,  Philadelphia,  1910    ...     66 

1 8.  Results  obtained  by  medical  inspectors  aided  and  not  aided  by 

school  nurses.     Philadelphia,  1910 67 

19.  Salaries  of  nurses  in  1 06  American  municipalities     ....     70 

20.  Physical  defects  reported  by  medical  inspectors,  and  number  and 

percent  of  these  defects  treated.     New  York  City,  191 1         .     92 

21.  Four  classes  of  physical  defects  reported  and  number  and  per  cent 

of  these  defects  treated.     Newark,  N.  J.,  1910-1 1    ...     93 

22.  Physical  defects  recommended  for  treatment  and  number  and 

percent  of  these  defects  treated.     Harrisburg,  Pa.,  1909-10  .     94 

23.  Physical  defects  reported  and  number  and  per  cent  of  these  defects 

treated.     Pasadena,  Cal.,  1909-10 94 

24.  Defects  reported,  number  referred  to  physicians,  and  per  cent  of 

these  in  which  physician  was  consulted.  Summit,  N.  J., 
1909-10 95 

25.  Defects  reported  and  the  number  and  per  cent  of  these  defects 

treated,  in  four  cities 96 

26.  Cases  of  physical  defects  treated  by  private  practitioners  and  by 

institutions,  New  York,  191 1 96 

27.  Percentages  of  cases  of  defects  of  eyes  and  ears  treated  profes- 

sionally.    Somerville,  Mass.,  1906-10 97 

28.  Recommendations  for  treatment  by  medical  inspectors  and  num- 

ber and  per  cent  of  treatments  in  24  English  areas.     1910       .     99 

29.  Number  and  salaries  of  medical  inspectors  and  school  nurses, 

average  school  attendance,  and  total  annual  expenditure  and 
expenditure  per  pupil  in  average  attendance  for  salaries  of 
medical  inspectors  and  school  nurses  in  77  American  cities  of 
more  than  8,000  population.  1911 104 

30.  Annual  salaries  of  physicians  and  nurses  in  all  cities  reporting        .    1 08 

31.  Results  of  dental  inspection  of  447  children,  ages  six  to  sixteen, 

Elmira,  New  York,  1910 115 

32.  Cities  of  the  United  States  having  dental  inspection  and  cities  hav- 

ing dental  inspection  by  dentists,  by  groups  of  states.     1911    122 

33.  Dental  inspection  of  school  children  in  twelve  German  municipal 

districts.     Year  ending  April,  191 1 126 

xvi 


LIST  OF   TABLES 

TABLE  PAGE 

34.  Administration  of  systems  of  medical  inspection  in  cities  of  United 

States,  by  groups  of  states.     1911 145 

35.  Per  cent  of  children  examined  found  defective,  among  907  "ex- 

empt" and  687  "  non-exempt "  children,  in  Philadelphia,  Penn.   1 52 

36.  Physical  defects   among  3,587  exempt   and    1,418  non-exempt 

children,  in  Philadelphia,  Penn.,  1908 153 

37.  Defects  of  vision  and  hearing  among  8, no  normal  and  2,020 

retarded  children  in  Camden,  N.J.,  1906  .        .        .        .        .    154 

38.  Physical  defects  and  irregular  attendance  among  1,279  normal 

and  573  retarded  children  who  failed  of  promotion  in 
Camden,  N.J.,  1906 154 

39.  Physical  defects  among  1,093  children  promoted  and  303  children 

not  promoted  in  elementary  schools,  in  Manchester,  Con- 
necticut, 1910 155 

40.  Physical  defects  among  449  retarded  children,  of  whom  345  had 

been  in  the  first  grade  two  years,  86  three  years,  and  18  four 

or  more  years.     Elmira,  New  York,  1909-10    .       .        .        .156 

41.  Per  cent  of  dull,  normal,  and  bright  pupils  suffering  from  each 

sort  of  defect.  Ages  ten  to  fourteen,  inclusive.  All  grades. 
New  York,  1908 158 

42.  Average  number  of  grades  completed  by  pupils  having  no  physical 

defects  compared  with  number  completed  by  those  suffer- 
ing from  different  defects.  Central  tendency  among  3,304 
children,  ages  ten  to  fourteen  years,  in  grades  one  to  eight. 
New  York,  1908 159 

43.  Extent  to  which  children  suffering  from  each  sort  of  physical 

defect  show  slower  progress  than  do  children  with  no  de- 
fects. New  York,  1908 160 

44.  Number  of  years  required  by  defective  and  non-defective  chil- 

dren to  complete  the  eight  grades.     New  York,  1908       .        .161 

45.  Principal  features  of  state  laws  and  regulations  providing  for 

medical  inspection.     1911  166 


xvn 


LIST  OF  FORMS 


PAGE 


Exclusion  card,  Brockton,  Massachusetts 22 

Monthly  report  of  medical  inspector,  Brockton,  Massachusetts    .        .  23 

Exclusion  notice  with  detachable  stub,  Chicago 25 

Envelope  daily  report  of  medical  inspector  in  which  are  forwarded  to 

Board  of  Health  copies  of  exclusion  notices,  Chicago          .       .  26 

Combined  directions  and  prescription,  Everett,  Mass 28 

Report  of  sight  and  hearing  tests  to  superintendents  of  schools, 

Massachusetts 48 

Snellen  chart  for  testing  eyesight 49 

Record  of  sight  and  hearing  tests,  Massachusetts 50 

Notice  to  parent  or  guardian  of  defect  of  eyes  or  ears,  Massachusetts   .  50 

Individual  record  card.     Physical  examinations,  Chicago,  111.       .       .  54 

Individual  record  card.     Physical  examinations,  Pasadena,  Cal.  .        .  55 

Individual  record  card  (Face,  Physical  Record).  Berkeley,  Cal.  .  56 
Individual  record  card  (Reverse,  Scholarship  Record).  Berkeley, 

Cal 57 

Notice  to  parent  or  guardian,  Massachusetts 73 

Post  card  notification  form,  Birmingham,  Alabama        ....  74 

Parent's  consent  blank,  St.  Louis,  Missouri 75 

Notification  of  defects  and  of  opportunities  for  consultation,  Oakland, 

California 77 

Notification  of  defects  and  of  opportunities  for  consultation,  Pasa- 
dena, California 78 

Notification  to  parents  of  school  physician's  office  hours         ...  79 
Notification  of  nurse's  call  and  of  school  physician's  office  hours,  Oak- 
land, California 79 

Agreement  between  dentists  and  schools,  Muskegon,  Mich.  .       .       .123 

Combined  directions  and  prescription  for  tooth  powder,  Philadelphia  .  128 
Individual  dental  record  Card,  Philadelphia  (Face)  .  .  .  .135 
Individual  dental  record  Card,  Philadelphia  (Reverse)  .  .  .  .136 

xix 


LIST   OF    FORMS 

PAGE 

Notice  to  parent,  Philadelphia 137 

Certificate  for  free  treatment,  Philadelphia 138 

Appointment  card,  Philadelphia 139 

Principal's  record,  Philadelphia                                                             .  140 

Weekly  report  of  dental  inspector,  Philadelphia 141 


xx 


CHAPTER  I 
THE  ARGUMENT  FOR  MEDICAL  INSPECTION 


M 


EDICAL  inspection  is  an  extension  of  the  activities  of 
the  school  in  which  the  educator  and  the  physician  join 
hands  to  insure  for  each  child  such  conditions  of  health 
and  vitality  as  will  best  enable  him  to  take  full  advantage  of 
the  free  education  offered  by  the  state.  Its  object  is  to  better 
health  conditions  among  school  children,  safeguard  them  from 
disease,  and  render  them  healthier,  happier,  and  more  vigorous. 
It  is  founded  upon  a  recognition  of  the  intimate  relationship 
between  the  physical  and  mental  conditions  of  the  children, 
and  the  consequent  dependence  of  education  on  health  conditions. 

When  Boston  initiated  medical  inspection  in  America  in 
1894,  by  dividing  her  schools  into  50  districts  and  placing  a 
physician  in  charge  of  each  district,  she  did  so  in  the  hope  that 
the  new  measure  would  curb  the  waves  of  contagious  disease 
that  repeatedly  swept  through  the  ranks  of  the  children,  leaving 
behind  a  record  of  suffering  and  death.  The  experiment  was 
successful,  and  when  other  cities  learned  how  Boston  was  solving 
the  problem,  they  too  began  to  employ  school  physicians  and  to 
organize  systems  of  medical  inspection. 

During  the  first  years  the  spread  of  the  movement  was 
slow,  only  one  or  two  cities  taking  it  up  each  year;  then  these 
pioneers  were  followed  by  dozens  of  their  sister  cities,  later  by 
scores,  and  in  the  past  few  years  by  hundreds. 

This  sudden  recognition  of  the  imperative  necessity  for 
safeguarding  the  physical  welfare  of  school  children  grew  out  of 
the  discovery  that  compulsory  education  under  modern  city  con- 
ditions meant  compulsory  disease. 

With  the  great  changes  which  have  been  coming  over 
American  life,  former  conditions  have  disappeared  and  undisturbed 
indifference  to  the  physical  welfare  of  our  school  children  has 
become  impossible.  We  have  changed  from  an  agricultural 


MEDICAL   INSPECTION   OF   SCHOOLS 

people  to  a  race  of  dwellers  in  towns  and  cities.  The  school 
year  has  changed  from  a  three  months'  winter  term  to  one  of  five 
hours  per  day  for  ten  months  during  the  year.  The  number  of 
years  of  school  life  has  greatly  increased.  We  have  passed  com- 
pulsory education  laws.  Going  to  school  has  become  not  only 
\>the  normal  but  the  required  occupation  of  all  children  for  a 
considerable  number  of  years. 

The  results  of  these  changed  conditions  on  the  health  of 
children  have  become  so  marked  as  insistently  to  demand  atten- 
tion. The  parents,  school  authorities,  and  health  authorities 
have  been  unable  to  avoid  recognizing  the  fact  that  in  the  nature 
of  the  case  the  school  has  become  the  most  certain  center  of 
.  infection  in  the  community. 

The  state,  to  provide  for  its  own  protection,  has  decreed 
that  all  children  must  attend  school,  and  has  put  in  motion  the 
all-powerful  but  undiscriminating  agency  of  compulsory  education, 
which  gathers  in  the  rich  and  the  poor,  the  bright  and  the  dull, 
the  healthy  and  the  sick.  The  object  was  to  insure  that  these 
children  should  have  sound  minds.  One  of  the  unforeseen  results 
was  to  insure  that  they  should  have  unsound  bodies.  Medical 
inspection  is  the  device  created  to  remedy  this  condition.  Its  ob- 
ject is  prevention  and  cure. 

Wherever  established,  the  good  results  of  medical  inspection 
have  been  evident.  Epidemics  have  been  checked  or  avoided. 
Improvements  have  been  noted  in  the  cleanliness  and  neatness 
of  the  children.  Teachers  and  parents  have  come  to  know  that 
under  the  new  system  it  is  safe  for  children  to  continue  in  school 
in  times  of  threatened  or  actual  epidemic. 

But  medical  inspection  does  not  stop  here,  nor  has  it  limited 
its  activities  to  the  field  outlined.  Other  problems  have  been 
insistently  forcing  themselves  on  the  attention  of  school  men;  and 
they,  knowing  something  of  the  wonderful  advances  made  in  the 
field  of  medicine,  have  turned  for  aid  to  the  physicians. 

With  the  changes  in  the  length  of  the  school  term,  and  the 
increase  in  the  number  of  years  of  schooling  demanded  of  the  child, 
has  come  a  great  advance  in  the  standards  of  the  work  required. 
When  the  standards  were  low,  the  work  was  not  beyond  the  capac- 
ity of  even  the  weaker  children;  but  with  close  grading,  fuller 

2 


ARGUMENT   FOR   MEDICAL   INSPECTION 

courses,  higher  standards,  and  constantly  more  insistent  demands 
for  intellectual  attainment,  conditions  have  changed.  Pupils 
have  been  unable  to  keep  up  with  their  classes.  The  terms  "  back- 
ward," "retarded,"  and  "exceptional,"  as  applied  to  school  chil- 
dren, have  been  added  to  the  vocabularies  of  school  men. 

School  men  discovered  that  the  drag-net  of  compulsory 
education  was  bringing  into  school  hundreds  of  children  who 
were  unable  to  keep  step  with  their  companions,  and  because 
this  interfered  with  the  ordinary  administration  of  our  school 
systems  they  began  to  ask  why  the  children  were  backward. 

The  school  physicians  helped  to  find  the  answer  when  they 
showed  that  hundreds  of  these  children  were  backward  simply 
because  of  removable  physical  defects.  And  then  came  the 
next  great  forward  step,  the  realization  that  children  are  not 
dullards  through  the  will  of  an  inscrutable  Providence,  but  rather 
through  the  law  of  cause  and  effect. 

This  led  to  an  extension  of  the  scope  of  medical  inspection 
to  include  the  physical  examination  of  school  children  with  the 
aim  of  discovering  whether  or  not  they  were  suffering  from  such 
defects  as  would  handicap  their  educational  progress  and  prevent 
them  from  receiving  the  full  benefit  of  the  free  education  furnished 
by  the  state.  This  work  was  in  its  infancy  five  years  ago,  but 
today  more  than  200  American  cities  have  systems  of  physical 
examination  of  their  school  children. 

Surprising  numbers  of  children  have  been  found  who,  through 
defective  eyesight,  have  been  seriously  handicapped  in  their 
school  work.  Many  are  found  to  have  defective  hearing.  Other 
conditions  are  found  which  have  a  great  and  formerly  unrecognized 
influence  on  the  welfare,  happiness,  and  mental  vigor  of  the  child. 
Attention  has  been  directed  to  the  real  significance  of  adenoids 
and  enlarged  tonsils,  of  swollen  glands  and  carious  teeth. 

Communities  are  seeing  the  whole  matter  in  a  new  light. 
Gradually  they  are  beginning  to  ask,  not  whether  they  can  afford 
to  take  steps  to  safeguard  in  schools  the  welfare  of  their  children, 
but  whether  they  can  afford  not  to  take  such  steps.  The  realiza- 
tion is  dawning  that  it  is  unbusinesslike  to  count  carefully  the 
cost  of  the  school  physician,  but  to  disregard  the  cost  of  death  and 
disease,  of  wrecked  hopes  and  dependent  families. 

3 


MEDICAL   INSPECTION   OF   SCHOOLS 

Teachers  and  parents  are  beginning  to  realize  that  the  prob- 
lem of  the  pupil  with  defective  eyesight  may  be  quite  as  important 
to  the  community  as  that  of  the  pupil  who  has  some  contagious 
disease.  A  child  who  is  unable  to  see  distinctly  is  placed  in  a 
school  where  physical  defects  are  unrecognized  and  disregarded; 
headaches,  eyestrain,  and  failure  follow  all  his  efforts  at  study. 
He  cannot  see  the  blackboards  and  charts;  printed  books  are 
indistinct  or  are  seen  only  with  much  effort,  everything  is  blurred. 
Neither  he  nor  his  teacher  knows  what  is  the  matter,  but  he  soon 
finds  it  impossible  to  keep  pace  with  his  companions,  and,  becom- 
ing discouraged,  he  falls  behind  in  the  unequal  race. 

In  no  better  plight  is  the  child  suffering  from  enlarged 
tonsils  and  adenoids,  which  prevent  proper  nasal  breathing  and 
compel  him  to  keep  his  mouth  open  in  order  to  breathe.  Perhaps 
one  of  his  troubles  is  deafness.  He  is  soon  considered  stupid. 
This  impression  is  strengthened  by  his  poor  progress  in  school. 
Through  no  fault  of  his  own  he  is  doomed  to  failure.  He  neglects 
his  studies,  hates  his  school,  leaves  long  before  he  has  completed 
the  course,  and  is  well  started  on  the  road  to  an  inefficient  and 
despondent  life. 

Public  schools  are  a  public  trust.  When  the  parent  delivers 
his  child  to  their  care  he  has  a  right  to  insist  that  the  child  under 
the  supervision  of  the  school  authorities  shall  be  safe  from  harm 
and  shall  be  handed  back  to  him  in  at  least  as  good  condition  as 
when  it  entered  school.  Even  if  the  parent  does  not  insist  upon 
it,  the  child  himself  has  a  right  to  claim  protection.  The  child 
has  a  claim  upon  the  state  and  the  state  a  claim  upon  the  child 
which  demands  recognition.  Education  without  health  is  useless. 
It  would  be  better  to  sacrifice  the  education  if,  in  order  to  attain 
it,  the  child  must  lay  down  his  good  health  as  a  price.  Education 
must  comprehend  the  whole  man  and  the  whole  man  is  built 
fundamentally  on  what  he  is  physically. 

The  objection  that  the  state  has  no  right  to  permit  or  require 
medical  inspection  of  the  children  in  the  schools  will  not  bear 
close  scrutiny  or  logical  analysis.  The  authority  which  has  the 
right  to  compel  attendance  at  school  has  the  added  duty  of  insist- 
ing that  no  harm  shall  come  to  those  who  go  there.  The  Mass- 
achusetts law,  with  its  mandatory  "  shall,"  is  certainly  preferable 

4 


Mouth  breathing  means  adenoids;   adenoids  mean  deadened  intellects. 


ARGUMENT   FOR   MEDICAL   INSPECTION 

to  the  Connecticut  law,  with  its  permissive  "may."  The  exercise 
of  the  power  to  enforce  school  attendance  is  dangerous  if  it  is 
not  accompanied  by  the  appreciation  of  the  duty  of  seeing  that 
the  assembling  of  pupils  brings  to  the  individual  no  physical  detri- 
ment. When  the  subject  is  considered  both  from  the  standpoint 
of  the  individual  and  from  that  of  the  state,  the  wonder  is,  not 
that  medical  inspection  is  now  being  practiced,  but  rather  that 
it  was  not  begun  long  ago. 

Nor  is  the  state,  in  assuming  the  medical  oversight  of  the 
pupils  in  the  public  schools,  trespassing  upon  the  domain  of 
private  rights  and  initiative.  Under  medical  inspection  what  is 
done  for  the  parent  is  to  tell  him  of  the  needs  of  his  child,  of  which 
he  might  otherwise  have  been  in  ignorance.  It  leaves  to  the 
parent  the  duty  of  meeting  those  needs.  It  leaves  him  with 
a  larger  responsibility  than  before.  Whatever  view  be  taken  of 
the  right  of  the  state  to  enforce  measures  for  the  correction  of 
defects  discovered,  the  arguments  for  and  against  do  not  enter 
into  the  present  discussion.  It  is  difficult  to  find  a  logical  basis 
for  the  argument  that  the  state  has  not  the  right  to  inform  the 
parents  of  defects  present  in  the  child,  and  to  advise  as  to  remedial 
measures  which  should  be  taken  to  remove  them. 

The  justification  of  the  state  in  assuming  the  function  of 
education  and  in  making  that  education  compulsory  is  to  insure 
its  own  preservation  and  efficiency.  Whether  or  not  it  is  to  be 
successful  will  depend  on  the  intelligence  of  its  individual  members. 

But  the  well-being  of  a  state  is  as  much  dependent  upon  the 
strength,  health,  and  productive  capacity  of  its  members  as  it 
is  upon  their  knowledge  and  intelligence.  In  order  that  it  may 
insure  the  efficiency  of  its  citizens,  the  state  through  its  compulsory 
education  enactments  requires  its  youth  to  pursue  certain  studies 
which  experience  has  proved  necessary  to  secure  that  efficiency. 
Individual  efficiency,  however,  rests  not  alone  on  education  or 
intelligence,  but  is  equally  dependent  on  physical  health  and 
vigor.  Hence,  if  the  state  may  make  mandatory  training  in 
intelligence,  it  may  also  command  training  to  secure  physical 
soundness  and  capacity. 

Much  time  may  elapse  before  there  will  be  put  in  practice 
in  all  schools  the  measures,  now  so  successfully  pursued  in  some, 

5 


MEDICAL    INSPECTION    OF    SCHOOLS 

for  conserving  and  developing  the  physical  soundness  of  rising 
generations.  But  the  movement  is  so  intimately  related  to  the 
future  welfare  of  our  country,  and  has  so  signally  demon- 
strated its  value,  that  it  is  destined  to  be  universal  and  perma- 
nent. 

For  nineteen  centuries  the  educational  world  has  held  as 
the  most  perfect  expression  of  its  philosophy  that  half  line  of 
Juvenal  in  which  he  pleads  for  the  sound  mind  in  the  sound  body. 
It  has  remained  for  the  first  decade  of  the  twentieth  century  to 
awake  to  a  startled  realization  that  Juvenal  was  wrong — wrong 
because  he  bade  us  think  that  mind  and  body  are  separate,  and 
separately  to  be  provided  for. 

Only  now  have  we  come  to  realize  the  error  and  to  take 
steps  to  rectify  it.  Only  in  the  last  few  years  have  we  begun 
to  see  that,  educationally  at  least,  mind  and  body  are  inseparable, 
and  that  the  sound  mind  and  the  sound  body  are  inextricably 
related — both  causes  and  both  effects. 

All  these  things  mean  that  it  is  our  splendid  privilege  to 
see  and  to  be  a  part  of  a  movement  which  is  profoundly  trans- 
forming our  traditional  ideas  of  education.  They  mean  that  our 
children  and  our  children's  children  will  be  a  better  race  of  men 
and  women  than  are  we  or  than  were  our  fathers. 

Not  alone  our  unwillingness  to  be  outdone  in  this  public 
service  by  foreign  nations,  not  alone  our  sense  of  practical  fore- 
sight, but  our  inherent  feeling  of  obligation  toward  our  children 
and  our  recognition  of  this  service  as  one  of  necessity  for  the 
national  well-being,  are  forcing  upon  us  the  incorporation  of  this 
phase  of  public  activity  as  an  integral  part  of  our  public  education. 

The  human  race  will  be  a  better  race  because  of  the  lessons 
that  have  been  taught  us  by  the  child  having  contagious  disease, 
the  backward  child,  and  the  physically  defective  child.  Because 
of  these  lessons,  the  youth  of  the  future  will  attend  a  school  in 
which  health  will  be  contagious  instead  of  disease,  in  which  the 
playground  will  be  as  important  as  the  book,  and  where  pure 
water,  pure  air,  and  abundant  sunshine  will  be  rights,  and  not 
privileges.  He  will  attend  a  school  in  which  he  will  not  have 
to  be  truant,  tuberculous,  delinquent,  or  defective,  to  get  the 
best  and  fullest  measure  of  education. 

6 


M 


CHAPTER  II 
HISTORY  AND  PRESENT  STATUS 

ED  I  GAL  inspection  of  schools  was  first  provided  for  some 
eighty  years  ago  but  it  is  only  during  the  past  quarter 
of  a  century  that  it  has  assumed  the  proportions  of  a 
world-wide  movement.  It  is  found  in  all  the  continents,  and  the 
extent  of  its  development  in  different  countries  is  in  some  measure 
proportionate  to  their  degree  of  educational  enlightenment.  In 
the  most  important  countries  it  has  now  become  national  in  scope. 

FRANCE 

The  earliest  work  in  the  field  of  medical  inspection  seems 
to  have  been  done  in  France,  where  the  law  of  1833  and  the 
royal  ordinance  of  1837  charged  school  authorities  with  the  duty 
of  providing  for  the  sanitary  conditions  of  school  premises  and 
supervising  the  health  of  the  school  children.  A  few  years  later, 
irT  '[^42  and  1843,  governmental  decrees  were  promulgated  in 
Paris,  directing  that  all  public  schools  should  be  regularly  inspected 
by  physicians.  In  spite  of  these  early  beginnings,  however, 
it  was  not  until  1879  that  genuine  medical  inspection  in  the 
modern  sense  of  the  term  was  begun  in  France.  In  that  year 
the  general  council  of  the  Department  of  the  Seine  reorganized 
the  medical  service  in  the  schools  of  Paris  and  passed  an  appropri- 
ation for  the  payment  of  salaries  to  the  physicians.  Eight  years 
later  medical  and  sanitary  inspection  were  made  obligatory  in 
all  French  schools,  public  and  private. 

At  the  present  time  the  work  is  carried  on  in  Paris  by  a 
force  of  210  school  physicians  who  are  selected  on  the  basis  of 
competitive  examination  and  each  of  whom  has  supervision  of 
not  more  than  1,000  children.  These  physicians  visit  each  school 
at  least  twice  every  month  and  make  careful  examinations  of  the 
sanitary  conditions,  paying  special  attention  to  lightirfg,  ventila- 

7 


MEDICAL   INSPECTION   OF   SCHOOLS 

tion,  cleanliness,  and  water  supply.  Visits  are  made  to  each 
school  room  and  a  general  inspection  of  the  pupils  conducted. 
Following  this  general  inspection,  individual  examinations  are 
conducted  in  the  inspector's  private  room.  The  children  examined 
are  of  three  classes :  first,  those  whom  the  physicians  have  selected 
as  apparently  needing  special  attention;  second,  those  referred 
to  them  by  teachers  and  parents;  and  third,  those  who  have 
returned  to  school  after  absence  because  of  illness  or  some  unknown 
cause. 

The  first  object  of  the  examinations  referred  to  is  to  detect 
and  exclude  cases  of  contagious  disease.  In  addition  to  these 
inspections  each  child,  during  the  first  months  of  his  school  life, 
is  given  a  thorough  physical  examination,  and  a  careful  record  of 
the  findings,  entered  on  an  individual  record  sheet,  follows  the 
child  through  his  subsequent  school  career.  Every  six  months 
measurements  of  height  and  weight  are  made  and  the  results 
entered  on  these  record  sheets,  together  with  data  of  any  illnesses 
suffered  during  the  period,  and  the  results  of  subsequent  physical 
examinations.  Parents  are  informed  of  any  defect  or  disease 
discovered  and  urged  to  secure  remedial  treatment. 

In  other  cities  of  France  the  systems  followed  are  modeled 
after  that  of  Paris,  but  in  general  are  less  thorough,  and  in  the 
smaller  places  are  not  infrequently  restricted  to  inspections  for 
the  detection  and  exclusion  of  cases  of  contagious  disease. 

GERMANY 

In  Germany  the  city  of  Dresden  began  medical  inspection 
in  1867,  when  tests  of  vision  were  instituted.  The  first  genuine 
system  of  medical  inspection,  however,  appears  to  have  been 
inaugurated  by  Frankfort-on-the-Main,  which  appointed  a  school 
physician  in  1889,  an  example  which  was  soon  followed  by  many 
other  localities. 

In  the  city  of  Wiesbaden  a  plan  was  developed  that  was 
widely  copied  and  became  a  model,  not  only  throughout  the 
empire  but  in  other  countries.  The  plan  adopted  by  the  physi- 
cian on  his  monthly  visits  to  each  school  closely  resembles  that 
already  described  as  being  followed  in  Paris.  General  inspec- 
tions are  first  made  of  class  rooms  and  school  premises  and  these 

8 


HISTORY   AND    PRESENT   STATUS 

are  followed  by  individual  examinations  of  pupils  selected  be- 
cause they  are  suspected  of  suffering  from  contagious  diseases. 
Previous  to  entering,  each  child  has  been  given  a  physical  examina- 
tion, and  this  is  repeated  in  the  second,  fourth,  sixth,  and  eighth 
years  of  school  life.  On  each  of  these  occasions  an  examination 
of  heart,  lungs,  throat,  spine,  skin,  and  the  higher  sense  organs  is 
made,  and  (in  the  case  of  boys)  an  examination  for  hernia.  The 
findings  are  entered  on  a  report  blank  which  accompanies  the  child 
from  grade  to  grade.  Twice  a  year  the  teacher  records  the  height 
and  weight  of  individual  pupils.  Whenever  it  is  deemed  necessary, 
the  school  physician  takes  chest  measurements.  The  records  of 
children  who  seem  to  require  the  regular  care  of  a  physician  are 
marked  accordingly,  and  these  children  report  at  regular  intervals 
to  the  school  physician.  It  is  the  duty  of  the  school  physician 
to  give  advice  to  the  teacher  with  reference  to  the  child.  Parents 
are  notified  of  the  results  of  the  examinations. 

There  is  wide  variation  in  the  thoroughness  of  medical 
inspection  in  different  parts  of  the  empire.  Thoroughly  organized 
systems  under  state  regulations  exist  only  in  Saxe-Meiningen  and 
Hesse-Darmstadt  where  every  school,  both  public  and  private,  in 
the  country  as  well  as  in  the  city,  is  provided  with  a  state-appointed 
physician.  In  other  states  the  school  physicians  are  appointed 
by  and  work  under  the  municipal  Magistral,  the  local  board  of 
education,  or  the  board  of  health. 

In  the  year  1908  some  400  towns  and  cities  had  systems  of 
medical  inspection  of  schools,  employing  about  1,600  physicians. 
There  are  three  common  plans  of  employing  and  remunerating 
these  school  physicians.  Under  the  first  form  of  organization  the 
physician  is  employed  on  full  time,  is  paid  a  salary  ranging  from 
$1,750  to  $2,750  per  annum,  and  has  the  right  to  a  pension. 
Under  the  second  plan,  a  salary  of  from  $i  50  to  $250  a  year  is  paid 
for  part  time  services,  and  work  is  usually  carried  on  in  addition 
to  other  public  health  services,  for  which  separate  payment  is 
made.  Under  the  third  plan,  payment  is  made  on  a  per  capita 
basis,  according  to  the  number  of  children  inspected,  and  the 
scale  of  payment  ranges  from  6  to  16  cents  per  child  per  year,  the 
average  being  about  12  cents.  Payment  is  also  sometimes  made 
at  the  rate  of  from  60  cents  to  $i  .00  for  each  class  examined. 

9 


MEDICAL    INSPECTION    OF    SCHOOLS 

As  yet  the  movement  for  the  employment  of  school  nurses 
has  not  made  great  progress  in  Germany,  Charlottenburg  and 
Stuttgart  being,  in  1910,  the  only  cities  having  nurses.  On  the 
other  hand,  notable  progress  has  been  made  in  the  development 
of  other  movements  closely  allied  to  medical  inspection,  such  as 
open  air  schools,  school  feeding,  dental  inspection,  and  the  organi- 
zation of  special  classes  for  exceptional  children. 

GREAT  BRITAIN* 

In  England  and  Wales  the  medical  inspection  of  schools  is 
carried  on  under  the  provisions  of  the  Education  Act  of  1907  which 
is  mandatory  in  nature.  In  Scotland  the  work  is  carried  on  under 
the  Education  Act  of  1908  which  confers  on  school  boards  the 
powers  necessary  for  a  universal  system  of  medical  inspection.  In 
Ireland  alone  compulsory  medical  inspection  does  not  exist.  Such 
work  as  is  carried  on  is  in  the  main  performed  by  the  school  in- 
spectors of  the  national  board  of  education,  who  are  not  medical 
men. 

The  object  of  medical  inspection  in  Great  Britain,  as  stated 
by  the  memorandum  of  the  board  of  education,  is  "to  secure 
ultimately  for  every  child,  normal  or  defective,  conditions  of  life 
compatible  with  that  full  and  effective  development  of  its  organic 
functions,  its  special  senses,  and  its  mental  powers,  which  consti- 
tute a  true  education. "f 

While  medical  inspection  in  England  has  been  universal  and 
compulsory  only  since  the  passage  of  the  Act  of  1907,  it  has 
existed  in  London  since  1891,  when  the  first  school  physician  was 
appointed.  From  that  date  up  to  the  passage  of  the  National  Act 
the  development  of  the  movement  was  sporadic.  The  details 
of  organization  are  in  the  main  left  in  the  hands  of  the  local 
authorities,  subject  to  the  minimum  requirements  laid  down  by 
the  memorandum  of  the  board  of  education.  These  minimum 
provisions  include  the  physical  examination  of  each  pupil  at  the 
time  of  his  entrance  to  a  public  elementary  school,  and  if  possible 
three  subsequent  examinations,  the  first  of  which  takes  place 
during  the  third  year  of  school  life  or  about  the  seventh  year  of  age, 

*  For  full  discussion  of  the  English  law,  and  methods  of  enforcement,  see 
p.  1 74  if.  fSee  p.  176- 

10 


HISTORY   AND    PRESENT   STATUS 

the  second  during  the  sixth  year  of  school  life  or  about  the  tenth 
year  of  age,  and  the  third  at  the  time  the  child  is  about  to  leave 
school  and  go  to  work. 

England  was  the  pioneer  in  the  employment  of  school 
nurses,  the  first  having  been  appointed  in  London  as  early  as  1887. 
However,  the  first  school  nurses  in  the  modern  acceptation  of  the 
term  were  appointed  in  1901  by  the  London  school  board,  and  their 
employment  is  now  becoming  general  in  other  cities. 

OTHER  COUNTRIES 

In  Belgium  medical  inspection  is  the  rule  in  the  more  impor- 
tant municipalities,  and  Brussels  is  credited  with  having  estab- 
lished the  first  system  of  medical  inspection  in  the  full  modern 
sense  of  the  term  in  1874,  when  school  physicians  were  appointed 
and  charged  with  the  duty  of  inspecting  every  school  three  times 
a  month.  This  system  was  remarkably  successful  from  its  incep- 
tion, was  copied  in  other  cities  of  Belgium,  and  served  as  a  model 
for  systems  in  Switzerland.  Some  of  the  earliest  work  of  school 
dentists  and  oculists  was  done  in  Belgium. 

In  Norway  medical  inspection  has  progressed  steadily  since 
1885,  when  some  localities  began  to  support  regular  school  physi- 
cians. Permissive  regulations  were  passed  in  1889  and  were 
followed  two  years  later  by  mandatory  ones. 

Sweden  is  probably  the  country  where  the  term  "school 
physician"  was  first  used  in  its  modern  sense.  As  far  back  as  1868 
medical  officers  were  attached  to  the  staff  of  every  public  secondary 
school.  Their  duties  and  spheres  of  activity  have  been  progres- 
sively extended,  beginning  first  with  the  higher  schools,  and  since 
1895  including  the  primary  ones. 

In  Denmark  there  is  no  regular  system  of  medical  inspection 
nor  any  legislation  directly  providing  for  it.  Nevertheless,  some 
work  is  carried  on  in  the  elementary  and  secondary  schools  of  her 
larger  towns  and  cities,  Copenhagen  having  led  the  way  in  1896. 

Russia  has  made  provision  for  medical  inspection  since  1871 
but  with  a  few  exceptions  it  has  not  extended  beyond  the  secondary 
and  higher  schools. 

Austria  was  the  first  country  to  enact  effective  legislation 
providing  for  medical  inspection  in  the  elementary  schools,  by  a 

1 1 


MEDICAL    INSPECTION    OF    SCHOOLS 

ministerial  decree  of  1873  which  provided  for  the  regular  employ- 
ment of  school  physicians.  In  Hungary  the  office  of  school 
physician  was  established  by  the  act  of  1885. 

In  Bulgaria  organized  work  dates  from  1904,  while  in 
Roumania  adequate  legislation  has  existed  since  1899. 

In  Switzerland  the  medical  inspection  of  schools  and  school 
children  is  recommended,  but  not  enforced,  by  the  federal  govern- 
ment. Nevertheless  some  13  cantons  now  carry  out  the  recom- 
mended inspection  and  thorough  work  is  done  by  the  school 
physicians  of  some  cities. 

In  Japan  medical  inspection  has  been  compulsory  and 
universal  since  1898,  only  small  towns  and  country  districts  being 
exempt. 

In  Egypt,  Cairo  appointed  the  first  school  physician  in  1882, 
and  the  system  has  been  in  force  ever  since. 

In  Australia  and  Tasmania  the  work  dates  from  1906  and 
includes  not  only  measures  for  the  prevention  of  contagious 
diseases  but  physical  examinations,  together  with  much  scientific 
study  of  results.  This  renders  the  reports  from  these  countries 
unusually  valuable. 

In  America  a  number  of  countries  besides  the  United  States 
have  more  or  less  fully  developed  systems  of  medical  inspection. 
In  Canada,  Montreal  began  in  1906  with  the  appointment  of  50 
school  physicians.  ,  Halifax  and  Vancouver  followed  in  1907.  In 
all  of  the  provinces  there  is  inspection;  and  in  Ontario,  Manitoba, 
and  Alberta,  it  is  provided  for  by  law. 

In  Mexico  medical  inspection  dates  from  1896,  when  the 
department  of  medical  inspection  and  school  hygiene  was  organized 
under  the  director  general  of  elementary  instruction  and  a  few  phy- 
sicians were  appointed.  Since  that  time  there  have  been  several 
reorganizations  of  the  system,  with  constant  extension.  In  the 
city  of  Mexico  and  its  suburbs,  it  is  now  very  complete  and  notably 
efficient.  From  the  capital  the  work  has  spread  until  it  is  now 
fully  organized  in  the  state  of  Chihuahua,  and  partly  so  in  Guana- 
juato and  San  Luis  Potosi. 

In  South  America,  the  Argentine  Republic  and  Chile  began 
medical  inspection  in  1888  and  in  both  countries  the  systems  are 
thoroughly  developed. 

12 


A  throat  culture  in  time  may  save  nine  weeks  of  diphtheria. 


HISTORY   AND    PRESENT   STATUS 

DEVELOPMENT  AND  PRESENT  STATUS   IN  THE  UNITED   STATES 

Boston  was  the  first  city  in  the  United  States  to  establish 
a  regular  system  of  medical  inspection,  starting  in  1894  with  a  staff 
of  50  school  physicians.  The  movement  came  as  a  result  of  a 
series  of  epidemics  among  the  school  children.  Chicago  began  in 
1895.  New  York  City  followed  in  1897  when  the  board  of  health 
appointed  a  corps  of  134  medical  inspectors  for  the  public  schools, 
and  Philadelphia  in  1898.  In  all  these  instances  medical  inspec- 
tion in  its  inception  had  as  its  sole  object  the  reducing  of  the 
number  of  cases  of  contagious  disease  among  the  pupils.  The 
movement  rapidly  spread  from  the  greater  cities  to  the  smaller 
ones,  the  first  step  in  many  cases  being  taken  by  a  local  med- 
ical society  offering  to  carry  on  the  work  for  a  limited  time  with- 
out expense  to  the  municipality,  in  order  to  demonstrate  its 
desirability. 

BEGINNINGS  OF  STATE  LEGISLATION  * 
So  rapidly  and  convincingly  did  the  movement  establish 
itself  that  it  was  soon  provided  for  by  laws  in  the  more  progressive 
states.  In  1899  the  legislature  of  Connecticut  passed  a  law  provid- 
ing for  the  testing  of  vision  in  all  the  public  schools  of  the  state. 
New  Jersey  authorized  boards  of  education  to  employ  medical 
inspectors  in  1903.  In  the  following  year  Vermont  enacted  a  law 
requiring  the  annual  examination  of  the  eyes,  ears,  and  throats 
of  school  children. 

The  first  mandatory  legislation  providing  for  state-wide 
medical  inspection  in  all  public  schools  was  passed  by  Massachu- 
setts in  1906.1  From  these  beginnings  the  movement  spread 
rapidly  until  by  1912  seven  states  had  passed  mandatory  laws,  10 
had  passed  permissive  ones,  and  in  two  states  and  the  District 
of  Columbia  medical  inspection  was  carried  on  under  regulations 
promulgated  by  the  boards  of  health  and  having  the  force  of  law.f 
The  fact  that  the  Massachusetts  statute,  passed  in  1906,  is  the 
oldest  of  the  laws  now  in  force,  shows  that  the  whole  body  of 
legislative  enactments  which  crystallize  the  views,  beliefs,  and  the 

*  See  also  Chap.  XII,  Legal  Provisions,  p.  164  ff. 
f  See  pp.  164,  1 68,  and  177.  J  See  map,  p.  165. 

'3 


MEDICAL   INSPECTION   OF    SCHOOLS 

results  of  experience  of  educators  and  physicians,  is  of  distinctly 
recent  origin. 

PRESENT  STATUS 

The  best  body  of  evidence  as  to  the  present  status  of  medical 
inspection  in  American  municipalities  is  furnished  by  the  results 
of  an  investigation  conducted  by  the  Russell  Sage  Foundation 
during  the  school  year  1910-11.  This  investigation  gathered  the 
facts  on  medical  inspection  and  school  hygiene  from  1,046  school 
systems  in  1,038  cities  and  towns,  or  nearly  90  per  cent  of  the 
American  municipalities  which  have  regularly  organized  systems 
of  public  schools  under  superintendents.  For  the  purpose  of 
tabulating  the  results,  the  states  of  the  union  were  divided  into 
five  groups,  following  the  order  adopted  by  the  Bureau  of  the 
United  States  Census.  These  groups  are  as  follows: 


Maine 

New  Hampshire 

Vermont 


NORTH    ATLANTIC    DIVISION 

Massachusetts 
Rhode  Island 
Connecticut 


New  York 
New  Jersey 
Pennsylvania 


Delaware 
Maryland 
District  of  Columbia 


SOUTH    ATLANTIC    DIVISION 

Virginia 
West  Virginia 
North  Carolina 


South  Carolina 

Georgia 

Florida 


Kentucky 
Tennessee 
Alabama 


SOUTH   CENTRAL    DIVISION 


Mississippi 

Louisiana 

Texas 


Arkansas 
Oklahoma 


Ohio 
Indiana 
Illinois 
Michigan 


NORTH    CENTRAL    DIVISION 

Wisconsin 
Minnesota 
Iowa 
Missouri 


North  Dakota 
South  Dakota 
Nebraska 
Kansas 


Montana 
Wyoming 
Colorado 
New  Mexico 


WESTERN    DIVISION 

Arizona 
Utah 
Nevada 
Idaho 

14 


Washington 

Oregon 

California 


HISTORY   AND    PRESENT   STATUS 


Forty-three  per  cent  of  the  cities  and  towns  which  reported 
to  the  Foundation  had  regularly  organized  systems  of  medical 
inspection  in  their  public  schools.  The  number  of  municipalities 
reporting,  the  number  having  systems  of  medical  inspection,  and 
the  per  cent  having  such  systems  in  each  state  group,  are  shown  in 
the  following  table: 

TABLE   I. — CITIES  OF  UNITED  STATES  HAVING  MEDICAL  INSPECTION, 
BY  GROUPS  OF  STATES.   IQI  I 


CITIES    HAVING  MEDICAL 

Division 

Cities 
reporting 

INSPECTION 

Number 

Per  cent 

North  Atlantic 

411 

236 

57 

South  Atlantic 

74 

23 

3i 

South  Central 

101 

35 

35 

North  Central 

382 

109 

29 

Western 

70 

40 

57* 

United  States        

1,038* 

443 

43 

a  Representing  1,046  school  systems. 

The  percentage  figures  in  the  final  column  show  that  medical 
inspection  has  made  the  best  progress  in  the  North  Atlantic  and 
Western  divisions,  where  57  per  cent  of  the  cities  had  taken  up  the 
new  work.  In  the  two  southern  divisions  the  percentages  are  31 
and  35,  and  the  poorest  showing  is  made  by  the  North  Central 
division,  where  only  29  per  cent  of  the  cities  had  medical  inspec- 
tion systems. 

It  has  been  stated  that  the  first  system  of  medical  inspection 
was  inaugurated  by  Boston  in  the  year  1894.  Ten  years  later, 
in  1904,  36  cities  and  towns  had  such  systems.  From  this  time  on, 
the  increase  was  exceedingly  rapid  until  in  1911,  as  shown  above, 
the  number  of  municipalities  which  had  systems  of  medical 
inspection  had  increased  to  nearly  450.  Out  of  the  443  cities  and 
towns  reporting  systems  of  medical  inspection,  32  did  not  state 
the  year  in  which  work  began.  From  the  records  of  the  41 1  cities 

15 


MEDICAL    INSPECTION    OF    SCHOOLS 

which  gave  this  information  a  table  has  been  compiled  showing 
the  total  number  of  cities  having  medical  inspection  systems  in 
each  year  since  the  pioneer  work  in  Boston. 

TABLE  2. — CITIES  OF  UNITED  STATES  HAVING  SYSTEMS  OF  MEDICAL 
INSPECTION  IN  EACH  YEAR  FROM   1894  TO   IQI  I 


Year 

Cities  having  medical 
inspection 

1804 

1807 

E 

1898  

8 

1899  

1900  

9 
1  1 

IQOI 

17 

IQO2 

23 

IQO3 

28 

1904  
1905  
1906  

37 
55 
77 
in 
167 

IQOQ 

f* 

263 

IQIO 

4OO 

191  I          ....... 

41  1 

The  reason  for  the  comparatively  slight  increase  in  the  year 
1911  is  that  the  data  were  gathered  in  the  early  spring,  so  that 
cities  which  adopted  medical  inspection  later  in  the  year  were  not 
included. 

The  chart  on  page  17  represents  graphically  the  number  of 
cities  having  medical  inspection  each  year  since  1894,  and  shows 
how  the  growth  of  the  movement,  at  first  slow  and  gradual,  has 
become  in  the  later  years  increasingly  rapid. 

SCHOOL  PHYSICIANS 

The  returns  of  the  investigation  show  that  354  of  the  443 
cities  having  systems  of  medical  inspection,  or  about  80  per  cent 
of  them,  employed  school  physicians,  and  that  the  total  number 
of  physicians  employed  was  1,415.  More  than  half  of  these  were 
in  the  North  Atlantic  states  and  more  than  half  of  the  remaining 
number  in  the  North  Central  states.  Their  distribution  in  the 
several  divisions  is  shown  in  Table  3. 

16 


HISTORY   AND    PRESENT   STATUS 


'10 


'11 


'O9 


'06 


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70€> 


Off 


04 


55300 


en  dad] 

eon 


ZQ 


$Z  7?    Mt 

DIAGRAM  I.  —  CITIES  OF  UNITED  STATES  HAVING  SYSTEMS  OF  MEDICAL  INSPEC- 
TION IN  EACH  YEAR  FROM  1894  TO  1911. 


TABLE   3.  —  CITIES  OF  UNITED  STATES  HAVING  SYSTEMS  OF  MEDICAL 

INSPECTION,  CITIES  EMPLOYING  SCHOOL  PHYSICIANS,  AND 

NUMBER  OF  PHYSICIANS  EMPLOYED,  BY  GROUPS 

OF  STATES.   I9II 


Division 

Cities  having 
systems  of  med- 
ical inspection 

Cities  employ- 
ing school 
physicians 

Number  of 
physicians 
employed 

North  Atlantic  .... 
South  Atlantic  .... 
South  Central    .... 
North  Central    .... 
Western      

236 
23 

35 
109 
40 

215 

14 

27 
70 
28 

852 
48 
4i 
417 
57 

United  States    .... 

443 

354 

i,4i5 

MEDICAL  INSPECTION  OF  SCHOOLS 

SCHOOL  NURSES 

The  school  nurse  is  now  almost  universally  admitted  to 
be  one  of  the  most  necessary  adjuncts  of  a  well  developed  system 
of  medical  inspection.  The  total  number  employed  in  American 
cities  in  1911  according  to  the  returns  of  the  same  investigation 
was  415,  of  whom  375,  or  90  per  cent,  were  in  the  North  Atlantic 
and  North  Central  states.  Their  distribution  in  the  different 
divisions  was  as  follows: 


TABLE  4. — CITIES  OF  UNITED  STATES   HAVING  SYSTEMS  OF  MEDICAL 

INSPECTION,   CITIES   EMPLOYING  SCHOOL  NURSES,  AND  NUMBER 

OF  NURSES    EMPLOYED,  BY  GROUPS  OF  STATES.  191  I 


Division 

Cities  having 
systems  of  med- 
ical inspection 

Cities  employing 
school  nurses 

Number  of 
nurses  employed 

North  Atlantic 
South  Atlantic 
South  Central 
North  Central 
Western 

236 
23 
35 
109 
40 

52 
5 

248 

13 

261 
ii 

5 
114 

24 

United  States    .... 

443 

102 

415 

DENTAL  INSPECTION 

Increasing  attention  is  being  paid  in  American  schools 
to  the  inspection  of  children's  teeth,  and  the  work  is  being  more 
and  more  commonly  carried  on  as  a  branch  of  medical  inspection 
in  a  semi-independent  way.  In  a  number  of  the  large  cities  the 
local  dental  associations  have  established  clinics  at  which  school 
children  are  given  treatment  either  gratis  or  at  small  expense. 
In  most  of  these  cases  dentists  serve  without  remuneration,  but 
in  a  few  cities  they  have  been  added  as  regularly  paid  members  of 
the  corps  of  medical  inspectors.  Sixty-nine  cities  had  dental 
inspection  conducted  by  dentists  in  1911,  and  of  these,  54,  or  78 
per  cent,  were  in  the  North  Atlantic  and  North  Central  states. 
Their  distribution  by  divisions  was: 

18 


HISTORY   AND    PRESENT   STATUS 


TABLE  5. — CITIES  OF  UNITED  STATES  HAVING  SYSTEMS  OF  MEDICAL 

INSPECTION,  AND  CITIES  EMPLOYING  SCHOOL  DENTISTS,  BY 

GROUPS   OF   STATES.   II  I 


Division 

Cities  having  systems 
of  medical  inspection 

Cities  employing 
school  dentists 

North  Atlantic 
South  Atlantic 
South  Central 
North  Central 
Western          .                      . 

236 
23 
35 
109 
40 

24 

3 
30 
4 

United  States         .... 

443 

69 

FOUR  PRINCIPAL  FEATURES  OF  MEDICAL  INSPECTION 
Systems  of  medical  inspection  in  different  parts  of  the  United 
States  vary  from  simple  and  rudimentary  ones  to  the  more  com- 
plex organizations  designed  to  safeguard  every  phase  of  the  child's 
physical  life  in  the  school.  There  are  four  principal  features  which 
constitute  component  parts  of  these  different  systems,  and  they 
are  found  in  almost  every  possible  combination.  These  features 


1.  Medical  inspection  conducted  by  physicians  for  the  detec- 
tion and  exclusion  of  cases  of  contagious  diseases; 

2.  Examinations  conducted  by  teachers  for  the  detection  of 
defects  of  vision  and  hearing; 

3.  Examinations  conducted  by  physicians  for  the  detection  of 
defects  of  vision  and  hearing; 

4.  Complete  physical  examinations  conducted  by  physicians. 

The  figures  showing  how  these  different  features  are  com- 
bined in  the  systems  of  medical  inspection  in  this  country  reveal 
the  relatively  chaotic  condition  and  lack  of  uniformity  existing 
in  this  branch  of  educational  work.  These  conditions  are  shown 
in  Table  6. 

The  data  that  have  been  reviewed  show  that  443  school 
systems  out  of  the  i  ,046  which  reported  had  regularly  organized 
systems  of  medical  inspection  in  1911.  But  these  data  fall  far 
short  of  doing  justice  to  the  situation  in  the  United  States.  While 

19 


MEDICAL    INSPECTION    OF    SCHOOLS 

it  is  true  that  only  443  systems,  or  about  42  per  cent  of  all,  had 
regularly  organized  work,  722  systems,  or  nearly  69  per  cent,  were 
carrying  on  some  sort  of  medical  inspection. 

TABLE    6. — STATUS    OF    MEDICAL    INSPECTION   IN    1,046    MUNICIPAL 

SCHOOL   SYSTEMS    IN   THE   UNITED   STATES.      IQII.      (THE   x's 

INDICATE    FEATURES   INCLUDED.) 


Inspection  for 
contagious 
disease 

Vision  and 
bearing  tests  by 
teachers 

Vision  and 
hearing  tests  by 
physicians 

Physical 
examinations 
by  physicians 

Number  of 
school  systems 
having  the  fea- 
tures specified 

X 

277 

X 

X 

92 

X 

X 

X 

80 

X 

X 

X 

X 

65 

X 

X 

X 

52 

X 

X 

X 

43 

X 

37 

X 

X 

32 

X 

X 

16 

X 

ii 

X 

X 

7 

X 

X 

X 

4 

X 

X 

3 

X 

X 

3 

Total         .............      722 

Systems  not  having  medical  inspection  of  any  kind        .       .       .      324 

Grand  total 1,046 

SUMMARY. — Medical  inspection  is  provided  for  by  law  in 
something  less  than  half  of  the  American  states.  Regularly 
organized  systems  of  medical  inspection  are  in  force  in  something 
less  than  half  of  the  American  cities,  while  a  beginning  has  been 
made  in  nearly  three-fourths  of  them.  About  four-fifths  of  the 
443  cities  having  systems  of  medical  inspection  employ  school  phy- 
sicians, almost  a  quarter  of  them  employ  school  nurses,  and  in 
about  one  city  in  seven  school  dentists  are  employed. 


20 


CHAPTER  III 

INSPECTION  FOR  THE  DETECTION  OF 
CONTAGIOUS  DISEASES 

NEARLY  all  American  systems  of  medical  inspection  have  had 
for  their  object  at  the  time  of  their  inception  merely  the 
detection  of  cases  of  contagious  diseases  in  their  early  stages. 
To  this  simple  aim  have  always  soon  after  been  added  the  detection 
and  exclusion  of  parasitic  diseases. 

In  towns  and  small  cities  medical  inspection  of  this  sort  is 
a  comparatively  elementary  matter  involving  few  difficulties  in 
organization  or  administration.  In  such  places  the  teacher  who 
thinks  she  sees  suspicious  symptoms  in  one  of  her  pupils,  and  fears 
they  may  portend  the  beginning  of  some  illness,  notifies  the 
principal  of  her  fears.  He  notifies  the  school  physician  by  tele- 
phone or  messenger  and  the  physician  comes  to  the  school  and 
examines  the  pupil,  sending  him  home  if  necessary.  In  addition, 
provision  is  frequently  made,  as  in  the  Massachusetts  law,  that 
the  school  authorities  shall  refer  to  the  school  physician  for  exami- 
nation and  diagnosis  every  child  returning  to  school  after  absence 
on  account  of  illness  or  unknown  cause. 


BLANKS  AND  FORMS 

Such  simple  systems  as  those  outlined  require  little  in  the 
shape  of  blanks  or  forms.  Notification  cards  or  blanks  are  used 
for  informing  the  parents  of  the  exclusion  of  the  child,  and  weekly 
or  monthly  reports  are  made  out  by  the  school  physician  stating 
how  many  children  he  has  examined,  how  many  he  has  excluded, 
and  for  what  diseases,  and  what  other  diseases  he  has  found  which 
did  not  require  exclusion.  A  good  example  of  such  an  exclusion 
card  is  the  one  used  in  Brockton,  Massachusetts. 

21 


MEDICAL    INSPECTION    OF    SCHOOLS 
EXCLUSION   CARD,    BROCKTON,    MASSACHUSETTS 


Commonwealth  of  Massachusetts. 


CONTAGIOUS  DISEASE. 


NOTICE  TO  PARENT  OR  GUARDIAN. 
In  accordance  with  Chapter  502  of  the  Acts  of  1906,  you 

are  hereby  notified  that 

has  been  examined  by  me  as  School  Physician,  and  found  to 

have  symptoms  of 

This  child  is  excluded  from  the  schools  until  he  brings  a 
statement  from  a  regular  practitioner  certifying  his  complete  re- 
covery. 

School  Physician. 

...190 


The  monthly  report  of  the  medical  inspector  of  the  same  city 
is  also  a  good  specimen  of  forms  which  have  given  satisfaction  in 
simple  systems,  and  which  might  well  be  adapted  for  use  in  any 
locality  where  the  number  of  cases  handled  is  comparatively  small 
and  the  pupils  are  individually  known  to  the  school  authorities 
so  that  it  is  easy  to  keep  track  of  them. 

Large  systems  require  somewhat  more  complicated  organiza- 
tion and  records.  Efficiency  and  economy  of  labor  demand  that 
printed  forms  be  provided  wherever  their  use  obviates  the  neces- 
sity for  any  considerable  amount  of  writing.  The  same  considera- 
tion demands  that  on  these  forms  underlining  or  checking  of  printed 
words  be  used  wherever  possible,  instead  of  the  filling  in  of  blank 
spaces.  The  object  is  to  attain  the  desired  results  with  a  minimum 
of  clerical  work  consistent  with  efficiency.  This  is  particularly 
important  when  the  clerical  work  is  to  be  performed  by  a  high- 
priced  man,  as  in  the  case  of  a  high-class  physician. 

Let  us  consider  a  case  where  the  school  physician  has 
examined  a  child  and  found  him  to  have  unmistakable  symptoms 

22 


INSPECTION    FOR   CONTAGIOUS   DISEASES 


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MEDICAL    INSPECTION    OF    SCHOOLS 

of  a  contagious  disease.  It  is  necessary  that  the  office  system 
enable  him  to  dispose  of  the  case  so  as  to  notify  fully  every  one  con- 
cerned. This  requires  (i)  an  exclusion  notice  to  be  sent  to  the 
parents;  (2)  a  record  for  the  school  authorities;  (3)  a  record  for 
the  board  of  health;  (4)  a  record  for  the  physician  himself. 

The  record  for  the  board  of  health  and  the  exclusion  notice 
require,  in  addition  to  the  name  of  the  child  and  the  disease,  the 
name  and  address  of  the  parent. 

Under  many  systems  these  notices  are  made  out  on  four 
separate  cards  or  sheets,  and  often  the  work  is  still  further  increased 
by  having  a  separate  card  for  the  record  of  exclusions  from  each 
room  in  the  school.  This  makes  it  necessary  to  secure  the  appro- 
priate card  before  the  record  can  be  made.  Under  such  conditions 
the  physician  spends  five  or  six  times  as  much  time  in  making 
entries  on  different  cards  as  he  does  in  inspecting  the  child. 

A  large  part  of  this  waste  of  time  and  money  can  be  obviated 
by  a  carefully  planned  system  of  records.  In  the  case  in  point,  for 
example,  the  work  can  be  greatly  reduced  by  adopting  a  system 
similar  to  the  one  in  use  in  Chicago.  Instead  of  being  furnished 
with  supplies  of  cards  for  making  the  several  records,  each  inspector 
is  given  a  book  similar  in  size  and  shape  to  an  ordinary  check  book. 
The  leaves  of  the  book  are  alternately  of  light  and  heavy  paper 
perforated  for  separation,  and  have  stubs  like  the  leaves  of  a 
check  book.  The  thin  leaves  and  stubs  are  printed  as  shown  on 
page  25. 

The  heavy  sheet  underneath  this  thin  leaf  is  an  exact  dupli- 
cate, except  that  in  the  lower  left  hand  corner  instead  of  the 
words  "  Hand  to  pupil  excluded"  it  has  the  words  "  Mail  this  card 
to  Chief  Medical  Inspector  same  day  pupil  is  excluded."  Between 
the  two  leaves  a  sheet  of  copying  carbon  is  inserted. 

When  an  exclusion  case  is  found  the  method  of  procedure  is 
simple.  The  inspector  fills  out  the  blank  and  its  stub.  The 
original  blank  is  the  exclusion  notice  and  is  taken  home  by  the 
pupil.  The  stub  is  handed  to  the  school  authorities  as  their 
record  of  the  case.  The  carbon  copy  on  the  heavy  sheet  is  torn  out 
to  be  sent  to  the  board  of  health  as  their  notification  of  the  case,  and 
the  stub  of  the  carbon  copy  is  left  in  the  book  as  the  inspector's 
record. 

24 


INSPECTION    FOR   CONTAGIOUS   DISEASES 


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MEDICAL    INSPECTION    OF    SCHOOLS 

.  Under  the  system  in  use  until  recently  in  Chicago  the  in- 
spector enclosed  all  the  carbon  copies  of  the  exclusion  notices  in  an 
envelope  and  forwarded  it  to  the  board  of  health.  This  envelope, 
besides  being  the  holder  for  the  exclusion  notices,  was  the  daily 
report  of  the  inspector.  On  its  face  were  blanks  to  be  filled  out  as 
follows : 

ENVELOPE   DAILY   REPORT  OF   MEDICAL   INSPECTOR   IN    WHICH   ARE 

FORWARDED  TO  BOARD  OF  HEALTH  COPIES  OF  EXCLUSION 

NOTICES.      CHICAGO 


CITY  OF  CHICAGO,  DEPARTMENT  OF  HEALTH 


MEDICAL  INSPECTION  OF  SCHOOLS 

Inspector's  Daily  Report  of  Number  of  Examinations  and  Exclusions 

I  have  this  day  examined pupils  at 

(NUMBER) 

the School,  made 

(NUMBER) 

cultures  for  bacterial  examination,  performed vacci- 

(  NUMBER) 

nations,  and  excluded pupils  from  attendance 

(NUMBER) 

at  school  for  reasons  stated  on  the  enclosed  exclusion  cards. 

Date 19        M.D. 

Medical  Inspector 

(Place  the  exclusion  cards  in  this  holder,  enclose  whole  in  special  envelope  and 
mail  to  Chief  Medical  Inspector.  Report  must  be  made  EVERY  SCHOOL  DAY 
whether  inspection  has  or  has  not  been  made.) 


The  saving  effected  by  this  system  is  plainly  seen  by  compar- 
ing the  number  of  forms  necessary  under  the  separate  card 
method  with  the  number  required  by  the  "check  book  and  carbon 
copy"  method: 

CHICAGO  METHOD  SEPARATE  CARD  METHOD 

1.  Notice  and  stub  i.  Notice  to  parents 

2.  Envelope  daily  report  2.  Record  for  school 

3.  Record  for  board  of  health 

4.  Record  for  inspector 

5.  Daily  report 
26 


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INSPECTION    FOR   CONTAGIOUS    DISEASES 

This  system  has  been  described  at  length  because  the 
principle  underlying  it  is  fundamental.  If  medical  inspectors  are 
to  do  efficient  work  they  must  not  be  overburdened  with  complex 
clerical  work.  The  aim  in  every  case  must  be  the  smallest  possible 
number  of  original  entries. 

One  commendable  time-saving  device  which  has  been 
adopted  in  some  cities  is  that  of  having  cards  for  different  uses 
in  different  colors  so  that  the  medical  inspector  can  put  his  hand 
on  the  card  he  wants  without  a  moment's  delay.  Utica  and 
Syracuse,  New  York,  have  adopted  this  plan.  Thus,  in  Utica  the 
physical  record  card  is  white;  the  notice  to  parents  of  physical 
defects,  salmon  colored;  the  exclusion  card,  buff;  the  card  of 
directions  for  ridding  the  hair  of  vermin,  printed  in  English,  is  pink ; 
in  Italian,  cherry  color.  The  room  record  of  pupils  excluded  and 
re-admitted  is  lavender. 

In  a  number  of  cities  it  has  been  found  necessary  to  have 
some  of  the  cards  that  go  to  parents  printed  in  several  different 
languages. 

One  feature  which  nearly  all  American  systems  of  medical 
inspection  have  in  common  is  the  plan  of  supplying  printed 
directions  for  ridding  the  hair  of  vermin.  One  of  the  best  of  these 
is  that  followed  in  Everett,  Massachusetts,  where  the  pupil  is  not 
only  instructed  as  to  treatment,  but  is  furnished  with  a  druggist's 
prescription  for  the  material  required.  This  plan  is  adopted  not 
only  for  cases  of  pediculosis  (lice),  but  for  other  common  com- 
plaints, such  as  impetigo  contagiosa,  ringworm,  and  scabies.  The 
forms  used  are  reproduced  on  pages  28  and  29. 


CO-OPERATION  OF  THE  TEACHER 

Experience  has  demonstrated  that  the  highest  efficiency  in 
medical  inspection  can  be  secured  only  through  the  constant 
co-operation  of  the  teachers.  In  the  matter  of  detecting  cases  of 
contagious  disease,  the  best  results  are  secured  by  a  compromise 
between  the  system  of  relying  entirely  upon  the  teacher  for  detect- 
ing symptoms  of  disease  and  that  of  insisting  that  the  physician 
alone  shall  make  the  inspection.  It  is  the  verdict  of  experience 
that  three  general  propositions  hold  true: 

27 


MEDICAL    INSPECTION    OF    SCHOOLS 
COMBINED   DIRECTIONS    AND    PRESCRIPTION,    EVERETT,    MASS. 


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INSPECTION    FOR   CONTAGIOUS   DISEASES 


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29 


MEDICAL    INSPECTION    OF    SCHOOLS 

1.  It  is  impracticable  to  have  the  physician  inspect  all 
the  pupils  every  day. 

2.  He   should    see   them    all    sometimes.     (In    some 
systems  such  routine  inspections  of  all  pupils  are  made  once 
in  two  weeks,  in  others  once  a  month,  and  in  still  others 
once  a  term.) 

3.  Where   school   nurses  are  employed   the  problem 
largely  disappears,  as  the  teacher  and  nurse  together  readily 
decide  which  pupils  should  go  to  the  inspector. 

In  localities  where  systems  have  been  carefully  worked  out, 
teachers  are  provided  with  printed  instructions  as  to  the  symptoms 
which  they  should  notice  and  on  account  of  which  children  should 
be  referred  to  the  school  physicians.  Probably  the  most  carefully 
worked  out  set  of  such  instructions  is  given  in  a  pamphlet  issued  by 
the  Massachusetts  state  board  of  education.  This  little  book, 
which  so  well  fills  the  need  that  it  has  been  reprinted  for  use  in 
many  other  localities  as  a  good  example  of  what  such  a  manual 
should  be,  is  reprinted  in  its  entirety  in  this  volume.*  Under  the 
heading  "Some  General  Symptoms  of  Disease  in  Children  which 
Teachers  should  Notice,  and  on  Account  of  which  the  Children 
should  be  Referred  to  School  Physician"  it  gives  explanatory 
directions  under  each  of  the  following  headings: 

Emaciation  Eruptions  of  any  sort 

Pallor  Cold  in  the  head  with  running  eyes 

Puifmess  of  the  face  Irritating  discharge  from  the  nose 

Shortness  of  breath  Evidence  of  a  sore  throat 

Swellings  in  the  neck  Coughs 

General  lassitude  and  other  evi-        Vomiting 

dences  of  sickness  Frequent  requests  to  go  out 
Flushing  of  the  face 

EXCLUSIONS 

In  most  cities  examinations  are  made  for  the  following 
diseases:  scarlet  fever,  diphtheria,  measles,  small-pox,  chicken-pox, 
tonsilitis,  pediculosis,  ringworm,  impetigo  contagiosa,  trachoma, 
and  other  transmissible  diseases  of  the  skin,  scalp,  and  eye.  Tu- 

*  See  Appendix  I,  p.  183. 
30 


No  exclusion  for  ringworm  when  cases  are  treated  by  the  nurse  at  school. 


First  aid  for  small  ailments  in  Toledo,  Ohio. 


INSPECTION    FOR   CONTAGIOUS    DISEASES 

berculosis,  when  thought  to  be  far  enough  advanced  to  be  a  menace 
to  public  health,  is  generally  reported  to  the  chief  medical  inspector 
before  the  pupil  is  excluded  from  school. 

In  general,  the  procedure  with  respect  to  the  more  common 
contagious  diseases  is  substantially  as  follows: 

Scarlet  fever  cases  are  not  allowed  to  return  to  school  until  all  des- 
quamation  is  completed  and  there  is  an  entire  absence  of  discharge  from 
the  ears,  nose,  throat,  or  suppurating  glands,  and  the  child  and  premises 
are  disinfected. 

Diphtheria  cases  are  excluded  until  two  throat  cultures  made  on 
two  consecutive  days  show  absence  of  the  Klebs-Loeffler  bacilli.  Those 
exposed  to  diphtheria  are  excluded  one  week  from  last  exposure. 

Measles  cases  are  excluded  for  three  weeks  or  longer  if  there  is 
present  bronchitis,  inflammation  of  the  throat  or  nose,  or  abscess  of  the  ear. 
Those  exposed  to  measles  are  excluded  two  weeks  from  the  date  of  last 
exposure. 

Whooping  cough  cases  are  excluded  until  after  spasmodic  stage  of 
the  cough — usually  about  eight  weeks.  Those  exposed  to  whooping 
cough  are  excluded  two  weeks  after  the  date  of  the  last  exposure. 

Mumps  cases  are  excluded  for  ten  days  after  all  swelling  has 
subsided. 

Chicken-pox  cases  are  excluded  until  the  scabs  are  all  off  and  the 
skin  smooth. 

Cases  oj  tonsilitis  are  excluded  on  clinical  evidence  alone  and  throat 
cultures  are  made  for  future  diagnosis. 

In  making  throat  examinations  wooden  tongue  depressors  are  used 
to  the  exclusion  of  all  other  tongue  depressors.  Each  tongue  depressor 
is  used  only  once  and  then  burned.  Aseptic  methods  are  employed  in  all 
examinations. 

When  children  are  excluded  sufficient  reasons  are  written 
briefly  on  an  exclusion  card  which  is  sent  to  the  parents.  One 
copy  is  filed  with  the  school  authorities  and  one  with  the  board  of 
health.  School  physicians  are  forbidden  to  make  any  suggestions 
as  to  treatment  and  management  of  sick  pupils.  This  rule  is 
nearly  universal  and  is  made  imperative. 

Children  recovering  from  measles,  whooping  cough,  mumps, 
chicken-pox,  scarlet  fever,  diphtheria,  and  small-pox  are  not  al- 
lowed to  re-enter  the  school  without  a  permit  from  the  department 


MEDICAL   INSPECTION    OF    SCHOOLS 


of  health.  If  they  have  been  taken  sick  with  any  of  these  infec- 
tious diseases  in  the  school  room,  the  pupils  of  the  room  are  dis- 
missed and  the  room  disinfected. 

In  the  accompanying  tables  figures  are  presented  showing 
the  number  of  exclusions  for  each  of  the  more  important  diseases 
in  four  cities.  In  Table  7  the  figures  are  the  original  data 
taken  from  the  latest  available  reports.  In  Table  8  the 
figures  are  relative,  showing  the  number  of  exclusions  for  each 
disease  among  each  thousand  children  excluded.  They  indicate 
the  variations  which  are  encountered  in  this  work.  These  varia- 
tions exist  not  only  between  cities  but  between  different  years  in 
the  same  city,  and  are  mostly  due  to  the  fluctuations  caused  by 
local  epidemics.  The  commonest  disorder,  and  the  one  causing 
the  largest  number  of  exclusions,  is  pediculosis. 

TABLE   7. — EXCLUSIONS    FOR  CONTAGIOUS  DISEASES  IN  FOUR  CITIES 


EXCLUSIONS 

Cause  of  exclusion 

Chicago 

Detroit 

Newark 

New  York 

1910 

1909-10 

1910-11 

1911 

Pediculosis    . 

i»455 

426 

925 

i,475 

Tonsilitis 

2,957 

170 

337 

Chicken-pox 

1,010 

90 

217 

1,347 

Mumps  . 

1,128 

33 

135 

i,475 

Impetigo 

986 

520 

227 

Measles 

1,004 

84 

'167 

414 

Conjunctivitis 

672 

1,137 

Scabies  . 

579 

254 

1*5 

215 

Diphtheria    . 

708 

7 

28 

848 

Ringworm     . 

116 

162 

138 

Whooping  cough 

298 

108 

83 

329 

Scarlet  fever 

579 

ig 

27 

198 

Other  causes 

2,783 

948 

1,925 

35i 

Total      

14,653 

2,775 

4,121 

8,154 

Further  data  showing  the  great  variations  between  cities 
in  the  matter  of  exclusions  are  presented  in  Table  9,  which 
compares  the  number  of  exclusions  with  the  total  school  mem- 
bership in  eight  cities.  The  figures  for  exclusions  are  taken 

32 


INSPECTION    FOR   CONTAGIOUS    DISEASES 


TABLE  8. — EXCLUSIONS  FOR  CONTAGIOUS  DISEASES  IN  FOUR  CITIES! 
RELATIVE  FIGURES  ON  THE  BASIS  OF  I  ,OOO  EXCLUSIONS  IN  EACH  CITY 


EXCLUSIONS 

Cause  of  exclusion 

Chicago 

Detroit 

Newark 

New  York 

1910 

1909-10 

1910-11 

1911 

Pediculosis    

99 

154 

224 

181 

Tonsilitis       

202 

61 

82 

Chicken-pox         .... 

69 

32 

53 

165 

Mumps  

77 

12 

33 

181 

Impetigo        

I87 

28 

Measles         

68 

30 

41 

51 

Conjunctivitis       .... 

46 

. 

140 

Scabies  

40 

92 

28 

26 

Diphtheria    

48 

2 

7 

104 

Ringworm     

34 

42 

39 

17 

Whooping  cough  .... 

20 

39 

20 

40 

Scarlet  fever         .... 

40 

7 

6 

24 

Other  causes         .... 

190 

342 

467 

43 

Total      

1,000 

1,000 

1,000 

1,000 

TABLE    9. — SCHOOL    MEMBERSHIP,     EXCLUSIONS     FOR    CONTAGIOUS 

DISEASE,    AND    NUMBER    OF     EXCLUSIONS     PER    THOUSAND     PUPILS 

ENROLLED,  FOR  EIGHT  CITIES 


EXCLUSIONS  FOR  CONTAGIOUS 

DISEASE 

City  and  year 

School 
membership 

Number 

Number  per 
thousand  pupils 

Chicago,  1910    .... 

301,172 

14.653 

49 

Cincinnati,  1910 
Cleveland,  1908-09  . 

47.454 
69,764 

i,  606 
i,798 

11 

Detroit,  1909-10 

57.996 

2,775 

48 

Newark,  1909-10 

57.742 

4,955 

86 

New  York,  1909-10  . 
Philadelphia,  1910    . 

744,148 
174,441 

8,884 
6,794 

12 

39 

Rochester,  1910 

26,664 

1,050 

39 

33 


MEDICAL   INSPECTION    OF    SCHOOLS 

from  the  annual  reports  as  indicated  in  the  table,  whereas  the 
figures  for  school  membership  are  those  given  in  the  report  of  the 
United  States  commissioner  of  education  for  the  corresponding 
years,  showing  the  total  number  of  different  pupils  enrolled  in  the 
day  schools.  The  figures  in  the  third  column  show  the  num- 
ber of  exclusions  per  thousand  children  enrolled.  The  significant 
feature  is  that  exclusions  range  all  the  way  from  12  per  thousand 
in  New  York  to  86  per  thousand  in  Newark. 

SUMMARY. — In  order  to  render  inspection  for  the  detection 
of  contagious  disease  effective,  the  most  important  feature  to  be 
striven  after  is  the  reduction  of  the  machinery  of  administration 
in  order  that  the  school  physicians  may  devote  the  largest  possible 
amount  of  time  and  energy  to  actual  inspection,  and  the  smallest 
to  merely  clerical  details. 

Experience  demonstrates  that  it  is  impracticable  to  have  the 
physicians  inspect  all  the  pupils  every  day,  and  it  is  equally  clear 
that  complete  inspection  should  be  made  occasionally. 

Where  the  work  is  done  successfully  and  adequately  the  num- 
ber of  cases  of  contagious  disease  among  the  children  is  greatly 
reduced,  and  the  necessity  for  closing  schools  because  of  epidemics 
is  largely  done  away  with.  Exclusions  on  account  of  contagious 
disease  during  the  school  year  vary  from  about  one  in  100  to  one 
in  10  of  the  school  membership.  The  lower  figure  is  approached 
only  when  school  nurses  are  a  part  of  the  permanent  corps  of  the 
school  medical  department. 


CHAPTER  IV 
PHYSICAL  EXAMINATIONS 

THE  theory  on  which  physical  examinations  are  based  rests 
on  a  different  foundation  from  that  underlying  medical 
inspection  for  the  detection  of  contagious  diseases.  The 
latter  is  primarily  a  protective  measure  and  looks  mainly  to  the 
immediate  safeguarding  of  the  health  of  the  community.  The 
former  aims  at  securing  physical  soundness  and  vitality  and  looks 
far  into  the  future. 

Physical  examinations  have  come  into  existence  because  of 
the  mass  of  evidence  showing  conclusively  that  a  large  percentage 
of  school  children — probably  from  one-tenth  to  one-fourth — suffer 
from  defective  vision  to  the  extent  of  requiring  an  oculist's  care  if 
they  are  to  do  their  work  properly,  and  if  permanent  injury  to  their 
eyes  is  to  be  avoided. 

These  conclusions  are  based  on  examinations  of  hundreds  of 
thousands  of  children  in  all  parts  of  the  world.  There  is  little 
doubt  as  to  the  substantial  accuracy  of  the  results.  More  than 
this,  a  considerable  percentage  of  school  children  are  so  seriously 
defective  in  hearing  that  their  school  work  suffers  severely. 
Most  important  of  all,  only  a  small  minority  of  these  defects  of  sight 
and  hearing  are  discovered  by  teachers  or  known  to  them,  to  the  parents, 
or  to  the  children  themselves.  When  children  attempt  to  do  their 
school  work  while  suffering  from  these  defects,  among  the  results 
may  be  counted  permanent  injury  to  the  eyes,  severe  injury  to  the 
nervous  system  due  to  eye  strain,  and  depression  and  discourage- 
ment, owing  to  inability  to  hear  and  see  clearly. 

Moreover,  there  are  other  defects,  in  particular  those  of  nose, 
throat,  and  teeth,  which  are  common  among  children  and  which 
have  an  important  bearing  upon  their  present  health  and  future 
development.  The  importance  of  these  defects  is  emphasized  by 
the  fact  that,  if  discovered  early  enough,  they  may  easily  be 

35 


MEDICAL    INSPECTION    OF    SCHOOLS 

remedied  or  modified,  whereas  neglect  leads,  almost  without  fail, 
to  permanent  impairment  of  physical  condition. 

In  America,  comprehensive  systems  embracing  thorough 
physical  examinations  of  all  pupils  are  still  far  from  general.  The 
investigation  conducted  by  the  Russell  Sage  Foundation  in  the 
spring  of  1911  showed  that  while  443*  cities  reported  systems  of 
medical  inspection,  in  only  214,  or  a  little  less  than  half,  did  the 
work  include  complete  physical  examinations  conducted  by  school 
physicians.  Moreover,  the  cities  having  physical  examinations 
were  mostly  in  the  North  Atlantic  division,  where  the  work  is 
oldest  and  most  highly  developed.! 

The  accompanying  table  presents  figures  showing  the  number 
of  cities  in  each  division  which  include  in  their  medical  inspection 
systems  full  physical  examinations  for  the  detection  of  defects. 
In  this  table  the  states  are  classified  by  divisions  according  to  the 
basis  adopted  by  the  United  States  Census. 

TABLE  10. — CITIES  OF  THE  UNITED  STATES  HAVING  EXAMINATIONS 
FOR  THE  DETECTION  OF  PHYSICAL  DEFECTS,  BY  GROUPS  OF  STATES. 

II  I 


Division 

Number  of  Cities 

North  Atlantic    
South  Atlantic     
South  Central      
North  Central     
Western       

135 

10 
12 
38 
19 

United  States      

214 

When  these  figures  are  compared  with  those  giving  the  entire 
number  of  cities  which  have  systems  of  medical  inspection,* 
they  show  that  the  cities  having  physical  examinations  are  more 
than  half  of  all  in  the  North  Atlantic  states,  less  than  half  of  all 
in  the  South  Atlantic  and  Western  ones,  and  only  about  one-third 
of  those  in  the  South  Central  and  North  Central  groups. 

*Seep.  15. 

t  Divisions  adopted  by  the  U.  S.  Census.     See  p.  14. 

36 


Listening  for  trouble.     Testing  heart  and  lungs  in  New  York  City. 


PHYSICAL   EXAMINATIONS 

CONDUCT  AND  RESULTS  OF  EXAMINATIONS 

Examinations  for  the  detection  of  physical  defects  are 
usually  conducted  after  the  school  physician  has  made  his  regular 
morning  inspection  for  the  detection  of  contagious  diseases.  The 
examinations  are  made  in  the  physician's  special  room,  which 
should  be  at  least  20  feet  long  in  order  to  allow  sufficient  space  for 
the  vision  tests.  In  the  older  school  buildings,  where  special 
rooms  are  not  provided,  the  hallways  are  frequently  utilized  as 
unsatisfactory  substitutes. 

The  children  are  brought  into  the  room  in  groups  of  three  or 
four,  and  in  making  the  examination  the  physician  usually  begins 
at  the  child's  head  and  proceeds  downward  over  the  body.  The 
object  of  the  examination  is  to  detect  such  physical  conditions  as 
interfere  with  the  child's  health  and  vitality  or  militate  against  his 
receiving  the  full  benefit  of  the  education  furnished  by  the  state. 
This  means  that  the  examinations  are  purely  practical  in  intent 
and  hence  they  should  avoid  unnecessary  refinement.  For  ex- 
ample, it  is  futile  for  the  physician  to  record  history  as  to  height 
and  weight  unless  some  real  end  is  to  be  attained  from  the  study 
of  these  data.  Again,  it  is  generally  useless  to  make  records  of 
physical  defects  so  unimportant  that,  although  their  existence  can 
be  detected,  they  do  not  require  attention  from  the  physician, 
oculist,  or  dentist. 

The  defects  which  are  looked  for,  and  which  should  be 
recorded,  are  defects  of  teeth,  throat,  eyes,  nose,  glands,  ears, 
nutrition,  lungs,  heart,  nervous  system,  and  bodily  structure. 

The  records  of  physical  examinations  show  that  from  one- 
half  to  two-thirds  of  all  the  children  examined  are  suffering  from 
physical  defects  sufficiently  serious  to  require  the  attention  of  the 
physician,  the  oculist,  and  the  dentist.  The  most  important  kinds 
of  defects  which  go  to  make  up  these  large  totals  are  those  of  teeth, 
throat,  eyes,  and  nose.  Indeed,  these  four  combined  constitute 
more  than  four-fifths  of  all  the  defects  found.  Table  n,  on  the 
following  page,  presents  the  data  showing  the  results  of  physi- 
cal examinations  among  more  than  half  a  million  children  in 
nine  American  cities.  The  significance  of  these  data  is  more 
clearly  shown  by  referring  to  Table  12,  which  presents  the  same 

37 


MEDICAL    INSPECTION    OF    SCHOOLS 


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PHYSICAL    EXAMINATIONS 

material  reduced  to  relative  form  so  as  to  show  the  conditions 
among  each  thousand  children  examined  in  each  of  the  cities. 

While  the  comparison  is  interesting  and  instructive,  the 
tables  do  not  give  an  entirely  accurate  comparative  view  of  condi- 
tions existing  among  the  school  children  of  the  different  cities. 
School  physicians  have  varying  standards  for  recording  the  differ- 
ent defects.  Moreover,  there  is  lack  of  uniformity  in  nomen- 
clature. In  the  present  case  adenoids  have  been  included  with 
defective  nasal  breathing  under  nose  defects,  and  hypertrophied 
tonsils  have  been  included  under  throat  defects.  Again,  figures 
for  defects  of  vision  and  hearing  are  lacking  for  Boston,  because 
in  that  city  the  examination  for  these  defects  is  conducted 
by  the  teachers  instead  of  by  the  physicians,  and  further 
blanks  in  the  table  are  caused  by  the  fact  that  New  York, 
Pasadena,  and  St.  Louis  do  not  report  cases  of  enlarged  cervical 
glands. 

Bearing  in  mind  these  considerations,  we  are  still  safe  in 
interpreting  the  table  as  showing  that  the  school  physicians  find 
about  65  per  cent  of  the  children  in  our  public  schools  to  be  suffering 
from  physical  defects  serious  enough  to  require  attention;  that  the 
most  common  are  those  of  teeth,  throat,  eyes,  and  nose;  and  that 
these  four  classes  of  defects  combined  constitute  about  85  per  cent 
of  all  those  discovered. 

Under  the  caption  "other  defects"  are  included  many 
abnormal  physical  conditions  varying  greatly  in  importance. 
Some  idea  of  the  variety  and  proportion  of  these  latter  may  be 
gained  from  Table  13,  which  shows  the  number  and  per  cent  of 
physical  defects  found  by  the  school  physicians  in  the  schools  of 
New  York  during  the  calendar  year  1911. 

The  publication  of  tables  similar  to  those  given  here  has 
resulted  in  many  misapprehensions  on  the  part  of  the  public 
and  those  specially  interested  in  the  public  schools.  It  has  been 
repeatedly  stated  that  results  of  physical  examinations  proved  that 
two-thirds  or  three-fourths  of  all  our  children  are  physically 
defective,  and  such  statements  have  aroused  much  discussion 
and  called  forth  some  denials.  The  difficulty  is  one  of  words 
rather  than  of  facts.  To  use  the  word  "defective"  as  it  has  been 
used  in  these  cases  is  to  give  it  a  new  and  somewhat  strained 

39 


MEDICAL    INSPECTION    OF    SCHOOLS 

meaning.  What  the  figures  really  show  is  that  a  large  proportion 
of  the  children  are  found  to  have  defects  serious  enough  to  need 
recording  and  to  require  attention  from  a  physician,  dentist,  or 
oculist.  Nevertheless,  the  defect  so  recorded  is  frequently  nothing 
more  serious  than  one  or  more  carious  teeth. 


TABLE     13. — RESULTS     OF     PHYSICAL     EXAMINATIONS     OF     SCHOOL 
CHILDREN,  NEW  YORK,  N.  Y.,   IQI  I 


Per  cent  of  all 

Number 

children 

examined 

Children  examined         

230,243 

100 

Needing  treatment        

166,368 

72.3 

Having: 

Defective  teeth  .... 

135.843 

59.0 

Hypertrophied  tonsils 

34.639 

15.0 

Defective  nasal  breathing 

27.319 

11.9 

Defective  vision         ... 

24,514 

10.6 

Malnutrition       .... 

5.845 

2.5 

Cardiac  disease  .... 

1,661 

•7 

Defective  hearing       ... 

1,491 

.6 

Orthopedic  defects     ... 

1,190 

•5 

Chorea         

86  1 

•4 

Pulmonary  disease     ... 

483 

.2 

Tuberculous  lymph  nodes 

418 

.2 

Defective  palates       ... 

85 

It  must  be  remembered,  too,  in  this  connection  that  the 
perfect  human  animal  is  exceedingly  rare.  The  figures  do  not 
mean  that  our  schools  are  filled  with  physical  wrecks.  They  do 
mean  that  the  results  of  examinations  prove  beyond  doubt  the 
need  for  finding  out  the  facts  and  taking  steps  to  have  the  defects 
remedied.  Experience  with  the  publication  of  results  of  medical 
inspection  demonstrates  no  less  clearly  the  imperative  need  for 
moderation  of  statement  in  making  the  results  public. 

FREQUENCY  OF  EXAMINATIONS 

American  practice  differs  from  that  in  vogue  abroad  in 
providing,  as  a  rule,  for  the  physical  examination  of  each  child 
annually  instead  of  at  less  frequent  intervals.  In  Germany  a 

40 


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c/5 


PHYSICAL    EXAMINATIONS 


child  is  examined  upon  his  entrance  into  the  public  school,  and  re- 
examined  in  the  third,  fifth,  and  eighth  school  years.  The  memo- 
randum of  the  English  board  of  education  provides  for  four 
examinations  during  the  child's  school  life, — upon  entrance,  and ' 
re-examination  in  the  third  and  sixth  years  and  upon  leaving.  To 
the  date  of  its  last  report  in  1911,  however,  the  board  had  required 
in  its  code  of  regulations  for  public  elementary  schools  only  two 
examinations,  one  of  "entrants"  and  one  of  prospective  "leavers,"/ 
although  the  known  intention  of  the  board  ultimately  to  demand 
the  inspection  of  a  third  intermediate  group  had  been  anticipated 
in  1910  by  some  hundred  local  authorities.  In  America  the  ideal  of 
annual  examinations,  almost  universally  held,  is  even  reflected  in 
several  of  the  state  laws. 

Unfortunately,  this  ideal  has  far  outrun  accomplishment  and 
in  few  instances  has  any  American  city  succeeded  in  examining  all 
of  its  children  in  any  one  year.  In  the  accompanying  table  figures 
are  presented  showing  the  number  of  pupils  enrolled  in  the  day 
schools  of  nine  cities  and  the  number  and  per  cent  of  children  who 
received  physical  examinations  in  the  same  cities. 

TABLE    14. — ENROLLMENT  IN    DAY  SCHOOLS  AND  NUMBER  AND   PER 
CENT   OF    PUPILS    EXAMINED    IN    NINE    CITIES 


City  and  year  of  examination 

Pupils  enrolled 
in  day  schools 
1909-10 

PUPILS  EXAMINED  FOR 
PHYSICAL    DEFECTS 

Number 

Per  cent 

Boston  —  1912  a 
Chicago  —  1910  . 
Cleveland  —  1910-11 
Newark  —  1910-11 
New  York  —  191  1 
Oakland  —  1910-11 
Pasadena  —  1909-10 
Rochester  —  1910 
St.  Louis  —  1910-11 

111,632 
301,172 
74,438 
57,742 
744,148 
1  6,  780  b 
5,622 
26,664 
87,931 

82,224 
120,301 
50,864 
24,310 
230,243 
16,015 
4,036 

15,157 
20,591 

73-7 
39-9 
68.3 
42.1 
30.9 

95-4 
71.8 
56.8 
23.4 

a  Partial  data. 


b  Figures  for  1908-09. 


The  percentages  given,  though  indicative  in  a  rough  way 
of  the  proportions  of  the  field  covered  in  the  several  cities,  should 
not  be  taken  too  seriously.  Thus,  in  view  of  the  impossibility  of 


MEDICAL    INSPECTION    OF    SCHOOLS 

securing  uniform  figures  in  regard  to  enrollment  for  the  years  dur- 
ing which  the  examinations  were  made,  it  was  found  necessary  to 
fall  back  on  the  report  of  the  United  States  commissioner  of 
education  for  1909-10.  The  figures  in  the  first  column  of  the  table, 
which  were  taken  from  this  report,  are  unsatisfactory  not  only 
because  they  are  of  too  early  a  date  but  because  they  include 
(presumably)  the  membership  of  high  schools,  which,  so  far  as 
known,  no  one  of  the  nine  cities  attempts  to  cover. 

The  situation  in  the  cities  showing  respectively  the  highest 
and  the  lowest  percentages — Oakland  and  St.  Louis — requires  a 
word  of  special  comment.  The  enrollment  figures  for  Oakland  are 
by  exception  for  the  year  1908-09,  while  those  for  children  examined 
are  for  1910-1 1,  a  fact  which  may  in  part  explain  the  very  high 
percentage  of  examinations  in  this  city.  A  greater  effort  was 
made  in  Oakland  than  elsewhere,  however,  to  examine  every 
child  in  the  primary  and  grammar  grades,  if  we  may  judge  from 
the  following  statement  made  by  the  director  of  health  develop- 
ment and  sanitation: 

"All  pupils  present  were  examined  during  the  first  term,  and  after 
the  Christmas  vacation  the  schools  were  gone  over  again  to  get  the  new 
scholars  and  those  missed  at  the  first  examination.  A  few  who  were 
absent  at  both  examinations,  or  who  have  entered  since  the  last,  are  not 
recorded." 

In  St.  Louis  the  efforts  of  the  department  of  school  hygiene 
are  chiefly  concentrated  on  19  schools  in  the  more  densely  popu- 
lated quarters  of  the  city,  practically  every  pupil  attending  which 
is  examined,  while  only  a  small  number  of  children  from  other 
schools  are  inspected  when  specially  referred  by  their  teachers  to 
the  school  physicians. 

In  general,  the  figures  indicate  that  five  out  of  the  nine  cities 
examined  more  than  half  of  their  school  children.  Of  Boston  it 
should  be  said  that  the  investigation  was  still  in  progress  at  the 
date  when  the  figures  given  were  reported,  and  that  it  was  the 
intention  to  continue  it  till  the  entire  school  population  was 
covered.  The  follow-up  system  in  this  city  seems,  however,  to 
be  less  highly  developed  than  that  in  New  York  and  other  cities 
which  show  a  far  lower  percentage  of  children  examined. 

42 


PHYSICAL    EXAMINATIONS 

It  should  be  remembered  that  in  general  these  data  represent 
unusually  good  conditions  rather  than  typical  ones.  It  would  be 
difficult  to  find  many  other  cities  with  equally  good  records  of 
accomplishment.  The  lesson  to  be  drawn  from  this  situation  is 
that  municipalities  should  aim  at  an  ideal  that  is  possible  of  attain- 
ment. It  would  be  far  better  to  plan  to  examine  each  child  once 
every  second  year  and  succeed  in  doing  so  than  to  attempt  to  do 
the  entire  work  every  year  and  fail.  It  would  also  be  far  bet- 
ter to  examine  children  in  alternate  years  and  employ  vigorous 
measures  to  secure  correction  of  defects  than  to  examine  every 
year  and  merely  notify  parents  of  the  need  of  treatment. 

TIME  AND  COST* 

Physical  examinations  of  the  sort  commonly  given  in  the 
better  American  systems  require  from  three  to  ten  minutes  each, 
depending  on  the  skill  of  the  examiner,  the  thoroughness  of  the 
examinations,  and  the  condition  of  the  pupils.  Perhaps  a  fair 
average  is  10  examinations  per  hour.  This  will  not  be  reached 
in  the  poverty-stricken  sections  of  our  great  cities,  where  the 
children  are  invariably  of  a  low  average  of  physical  condition, 
and  will  be  exceeded  in  the  more  prosperous  districts,  where  the 
children  are  much  more  nearly  normal. 

Although  10  examinations  per  hour  is  a  fair  average  on  which 
to  base  calculations,  it  must  be  remembered  that  one  examiner 
should  not  be  expected  to  do  this  work  much  more  than  two  or 
three  hours  per  day.  This  means  a  limit  of  from  20  to  30  examina- 
tions per  physician  per  day.  From  these  figures  an  estimate  of 
per  capita  cost  may  be  reached.  How  much  this  will  amount  to 
will  depend  not  only  on  the  rate  of  remuneration  of  the  physicians, 
but  to  a  considerable  degree  on  the  character  of  clerical  help 
afforded  him  for  recording  the  results  of  his  examinations. 

Probably  the  best  plan,  making  for  increased  efficiency  as 
well  as  economy,  is  to  have  the  school  nurse  or  the  room  teacher 
record  the  results  of  the  examinations.  In  the  latter  case  a  sub- 
stitute must  of  course  be  placed  in  charge  of  the  teacher's  room 
during  her  absence.  There  is  a  distinct  advantage  in  thus  enlist- 
ing the  active  sympathy  and  assistance  of  the  room  teacher. 

*  For  full  discussion  of  this  subject  see  Chap.  VIII,  p.  101  ff. 

43 


MEDICAL    INSPECTION    OF    SCHOOLS 


TESTS  OF  VISION  AND  HEARING 

There  are  some  differences  of  opinion  and  practice  as  to  the 
manner  of  conducting  tests  of  vision  and  hearing.  Probably  in 
a  majority  of  cities  which  conduct  physical  examinations  these 
tests  are  made  by  the  school  physicians.  There  are  many  locali- 
ties, however,  in  which  they  are  conducted  by  the  class  room 
teacher.  The  laws  and  regulations  of  1 1  states  provide  for 
physical  examinations,  and  in  seven  cases  provision,  either 
mandatory  or  permissive,  is  made  for  vision  and  hearing  tests 
by  teachers. 

There  can  be  little  doubt  that  this  practice  has  grown 
to  such  large  proportions  mainly  through  the  influence  of  the 
Massachusetts  statute  of  1906,  which  required  each  teacher  to 
test  the  sight  and  hearing  of  her  pupils  at  least  once  a  year  and 
to  report  the  results.  This  statute  is  still  in  force.  The  policy 
of  the  Massachusetts  legislators  in  making  mandatory  tests 
by  teachers,  rather  than  tests  by  specialists,  has  evoked  many 
expressions  of  surprise  and  some  of  criticism.  However,  the 
record  of  the  debates  which  took  place  before  the  passage  of  the 
law  shows  that  these  provisions  were  inserted  on  the  recommenda- 
tion of  the  specialists  themselves,  who  deemed  that  such  tests 
were  wholly  within  the  capacity  of  the  teacher.  It  was  their 
opinion  that  the  children,  if  examined  by  the  teacher,  would  be 
subjected  to  less  nervous  strain  than  if  tested  by  a  stranger  and 
would,  therefore,  respond  to  the  tests  in  a  more  natural  way. 
It  is  the  intention  of  the  Massachusetts  law  that  a  scientific 
examination  by  a  specialist  shall  be  made  in  any  case  where 
defects  are  apparently  revealed  by  the  teacher's  test. 

During  the  hearings  before  the  state  committee  on  ways 
and  means,  when  the  Massachusetts  medical  inspection  bill  was 
being  considered,  a  mass  of  evidence  was  presented  by  experts 
bearing  upon  the  question  as  to  whether  or  not  such  examinations 
could  be  successfully  conducted  by  teachers.  The  high  standing 
of  the  three  gentlemen  who  subscribed  to  it  makes  the  following 
opinion*  particularly  significant: 

*  Massachusetts  Civic  League,  Leaflet  No.  7,  p.  38. 
44 


PHYSICAL    EXAMINATIONS 

It  is  the  opinion  of  the  undersigned,  based  upon  professional  experi- 
ence, that  school  teachers,  with  the  aid  of  printed  directions  properly 
prepared,  are,  because  of  their  acquaintance  with  the  individual  children 
under  their  charge  and  their  consequent  ability  to  communicate  with 
them  and  to  find  out  what  is  in  their  mind,  more  capable  of  making  a 
satisfactory  examination  of  the  hearing  of  such  children  than  a  doctor 
other  than  a  specialist  called  in  for  the  purpose  would  be  likely  to  be. 

(Signed)     Clarence  John  Blake,  M.D. 
D.  Harold  Walker,  M.D. 
William  F.  Knowles,  M.D. 

The  same  opinion  was  expressed  by  other  experts  in  regard 
to  eyesight. 

The  methods  used  in  Massachusetts  have  proved  so  satis- 
factory after  several  years  of  statewide  use,  that  the  rules  for 
testing  are  here  quoted  in  full  as  a  guide  for  the  conduct  of  such 
examinations. 

SIGHT  AND  HEARING  TESTS  IN  MASSACHUSETTS 

Vision  and  hearing  tests  are  made  in  accordance  with  the 
following  directions  prescribed  by  the  state  board  of  health.  The 
materials  for  the  tests  are  distributed  to  all  teachers  by  the  state 
authorities. 

COMMONWEALTH  OF  MASSACHUSETTS 

Chapter  502,   Acts  of  1906 

Directions   for   Testing   Sight    and    Hearing 

(Prepared  by  State  Board  of  Health) 

To  TEST  THE  EYESIGHT 

Hang  the  Snellen  test  letters*  in  a  good,  clear  light  (side 
light  preferred),  on  a  level  with  the  head.  Place  the  child  20 
feet  from  the  letters,  one  eye  being  covered  with  a  card  held 
firmly  against  the  nose,  without  pressing  on  the  covered  eye, 
and  have  him  read  aloud,  from  left  to  right,  the  smallest 
letters  he  can  see  on  the  card.  Make  a  record  of  the  result. 
Children  who  have  not  learned  their  letters,  obviously,  can- 
not be  given  this  eyesight  test  until  after  they  have  learned 
them. 

To  RECORD  THE  ACUTENESS  OF  EYESIGHT 

There  is  a  number  over  each  line  of  test  letters,  which 

shows  the  distance  in  feet  at  which  these  letters  should  be  read 

*  See  p.  49. 

45 


MEDICAL    INSPECTION    OF    SCHOOLS 

by  a  normal  eye.  From  top  to  bottom,  the  lines  on  the  card 
are  numbered  respectively  50,  40,  30  and  20.  At  a  distance 
of  20  feet  the  average  normal  eye  should  read  the  letters  on  the 
20  foot  line,  and  if  this  is  done  correctly,  or  with  a  mistake  of 
one  or  two  letters,  the  vision  may  be  noted  as  |§,  or  normal. 
In  this  fraction  the  numerator  is  the  distance  in  feet  at  which 
the  letters  are  read,  and  the  denominator  is  the  number  over 
the  smallest  line  of  letters  read.  If  the  smallest  letters  which 
can  be  read  are  on  the  30  foot  line,  the  vision  will  be  noted  as 
|§;  if  the  letters  on  the  40  foot  line  are  the  smallest  that  can  be 
read,  the  record  will  be  f§;  if  the  letters  on  the  50  foot  line 
are  the  smallest  that  can  be  read,  the  record  will  be  |§. 

If  the  child  cannot  see  the  largest  letters,  the  50  foot 
line,  have  him  approach  slowly  until  a  distance  is  found  where 
they  can  be  seen.  If  5  feet  is  the  greatest  distance  at  which 
they  can  be  read,  the  record  will  be  -/^  (TV  of  normal). 

Test  the  second  eye,  the  first  being  covered  with  the 
card,  and  note  the  result,  as  before.  With  the  second  eye 
have  the  child  read  the  letters  from  right  to  left,  to  avoid 
memorizing.  To  prevent  reading  from  memory,  a  hole  \]4 
inches  square  may  be  cut  in  a  piece  of  cardboard,  which  may 
be  held  against  the  test  letters,  so  as  to  show  only  one  letter  at 
a  time,  and  may  be  moved  about  so  as  to  show  the  letters  in  ir- 
regular order.  A  mistake  of  two  letters  on  the  20  or  the  30  foot 
lines,  and  of  one  letter  on  the  40  or  50  foot  lines,  may  be  allowed. 

Whenever  it  is  found  that  the  child  has  less  than  normal 
sight,  f£,  in  either  eye,  that  the  eyes  or  eyelids  are  habitually 
red  and  inflamed,  or  that  there  is  a  complaint  of  pain  in  the 
eyes  or  head  after  reading,  the  teacher  will  send  a  notice  to 
the  parent  or  guardian  of  the  child,  as  required  by  law,  that 
the  child's  eyes  need  medical  attention. 

METHOD  OF  TESTING  HEARING 

If  it  is  possible,  one  person  should  make  the  examina- 
tions for  an  entire  school,  in  order  to  insure  an  even  method. 
The  person  selected  should  be  one  possessed  of  normal  hearing, 
and  preferably  one  who  is  acquainted  with  all  the  children,  the 
announcement  of  an  examination  often  tending  to  inspire  fear. 
The  examinations  should  be  conducted  in  a  room  not 
less  than  25  or  30  feet  long,  and  situated  in  as  quiet  a  place  as 
possible.  The  floor  should  be  marked  off  with  parallel  lines 


Vision  tests  by  physician  and  nurse  in  Orange,  N.  J. 


PHYSICAL    EXAMINATIONS 

one  foot  apart.  The  child  should  sit  in  a  revolving  chair  on 
the  first  space. 

The  examination  should  be  made  with  the  whispered  or 
spoken  voice;  the  child  should  repeat  what  he  hears,  and  the 
distance  at  which  words  can  be  heard  distinctly  should  be 
noted. 

The  examiner  should  attempt  to  form  standards  by  test- 
ing persons  of  normal  hearing  at  normal  distances.  In  a  still 
room  the  standard  whisper  can  be  heard  easily  at  25  feet,  the 
whisper  of  a  low  voice  can  be  heard  from  35  to  45  feet,  and  of 
a  loud  voice  from  45  to  60  feet. 

The  two  ears  should  be  tested  separately. 

The  test  words  should  consist  of  numbers,  i  to  100,  and 
short  sentences.  It  is  best  that  but  one  pupil  at  a  time  be 
allowed  in  the  room,  to  avoid  imitation. 

For  the  purpose  of  acquiring  more  definite  information 
concerning  the  acuteness  of  hearing,  one  may  have  recourse  to 
the  512  v.  s.  (vibrations  per  second)  tuning  fork  and  the 
Politzer  acoumeter. 

For  very  young  children  a  fair  idea  of  the  hearing  may 
be  obtained  by  picking  out  the  backward  or  inattentive  pupils, 
and  those  that  seem  to  watch  the  teachers'  lips,  placing  them 
with  their  backs  to  the  examiner,  and  asking  them  to  perform 
some  unusual  movement  of  the  hand,  or  other  act. 

The  sight  test  card  used  is  the  familiar  Snellen  chart.  A  re- 
production of  the  form  used  by  the  Massachusetts  authorities  is 
shown  on  page  49.  In  1910  "in  view  of  the  known  variations 
in  practice  both  in  recording  and  in  reporting,  and  in  the  hope 
that  the  tests  may  be  made  and  reported  uniformly"  the  state 
board  of  education  issued  the  following  supplementary  directions, 
prepared  by  the  board  of  health: 

1.  The  test  will  be  made  as  early  in  the  school  year  as  possible,  pref- 
erably in  September. 

2.  The  tests  will  be  made  under  the  most  favorable  conditions,  and 
as  nearly  as  possible  under  the  same  conditions,  preferably  in  well-lighted 
rooms,  in  the  early  part  of  the  day. 

3.  The  testing  will  be  done  by  the  teacher  of  the  class,  and  will 
be  supervised  by  the  principal  to  see  that  the  conditions  of  the  test  are 
as  uniform  as  possible  for  the  different  classes. 

47 


MEDICAL   INSPECTION    OF   SCHOOLS 

4.  Children  wearing  glasses  will  be  tested  with  the  glasses,  and  if 
found  normal  will  be  so  recorded. 

5.  Examine  all  children,  but  record  as  defective  only  those  whose 
vision  is  20/40  or  less,  in  either  eye. 

6.  Report  to  the  State  Board  of  Education  the  whole  number  of 
children  examined  and  the  number  found  defective  according  to  the  stand- 
ard given  in  No.  5. 

The  results  of  the  examinations  are  recorded  by  the  room 
teacher  on  double  sheets,  with  spaces  for  recording  the  results 
of  the  examination  of  50  pupils.  A  reproduction  of  the  sheet 
heading  is  given  on  page  50. 

A  report  of  the  results  for  each  school  is  forwarded  to  the 
superintendent  by  the  teacher  or  principal. 

REPORT  OF    SIGHT  AND    HEARING  TESTS  TO    SUPERINTENDENTS    OF 
SCHOOLS,    MASSACHUSETTS 


The  Commonwealth  of  Massachusetts 

Chap.  502,  Acts  of  1906 


Report  on  Sight  and  Hearing  Tests  to  Superintendent  of  Schools 


City 

or       [  School, 

Town 


Number  of  pupils  enrolled  in  the  school 
'     found  defective  in  eyesight 
'     found  defective  in  hearing 
"    of  parents  or  guardians  notified 


Teacher  or  Principal. 


In  addition  to  these  reports  the  teacher  is  required  to  notify 
the  parent  or  guardian  of  each  child  found  to  have  some  trouble 
with  the  ears  or  eyes.  Notification  cards  like  the  one  repre- 
sented on  page  50  are  furnished  by  the  state  board  of  education. 


PHYSICAL   EXAMINATIONS 


The  methods  described  for  making  tests  of  vision  and  hearing 
in  Massachusetts  are  typical  of  the  best  practice  in  other  states. 
The  practicability  of  having  these  tests  made  by  teachers  has  been 
abundantly  demonstrated  by  extensive  experience,  and  in  many 
localities  this  work  has  been  the  opening  wedge  for  the  establish- 
ment of  complete  systems  of  medical  inspection. 

According  to  the  investigation,  tests  of  vision  and  hearing 
were  in  1911  established  features  in  the  schools  of  552  municipali- 
ties. Moreover,  349  of  these  cities  had  begun  the  work  without 
legal  requirement,  for  they  are  located  in  states  which  had  not 
made  legal  provision  for  these  tests.  The  distribution  of  the  552 
municipalities  and  of  258  others  in  which  vision  and  hearing 
tests  are  made  by  physicians  is  as  follows: 

TABLE  15. — VISION  AND  HEARING  TESTS  CONDUCTED  BY  PHYSICIANS 
AND  TEACHERS   IN   AMERICAN   CITIES,    BY   GROUPS  OF   STATES. 

I9II 


Division 

Tests  by  physicians 

Tests  by  teachers 

North  Atlantic       .... 
South  Atlantic       .... 
South  Central         .... 
North  Central        .... 
Western  

125 

12 
23 

73 
25 

261 
29 
43 

37 

United  States         .... 

258 

552 

Data  are  available  giving  the  results  of  vision  and  hearing, 
tests  in  Massachusetts  for  the  years  1907-10  inclusive.     Similar 
data  for  Connecticut   and  Maine  for  the  years  1908  and  1911 
respectively  are  also  matters  of  record.     In  brief  summary  form, 
results  from  these  three  states  are  as  shown  in  Table  16. 

The  figures  for  Massachusetts  show  a  constant  and  somewhat 
rapid  falling  off  in  the  percentage  of  children  reported  each  year 
as  having  defective  vision  and  hearing.  Just  what  has  caused  this 
falling  off  is  difficult  to  determine,  and  indeed,  has  not  been 
satisfactorily  explained  by  the  educational  authorities  of  the  state. 
Whatever  the  cause  may  be,  the  more  important  lesson  of  the  table 


MEDICAL   INSPECTION    OF    SCHOOLS 


is  that  in  all  these  states  the  examinations  result  in  the  discovery 
each  year  of  many  thousands  of  pupils  with  defective  vision  and 
hearing.  This  means  that  each  year  large  numbers  of  these  chil- 
dren receive  treatment  for  defects  which  otherwise  would  in  all 
probability  have  continued  uncared  for  and  would  have  con- 
stantly grown  more  serious. 

TABLE  1 6. — RESULTS  OF  VISION  AND  HEARING  TESTS   IN  MASSACHU- 
SETTS, CONNECTICUT,  AND  MAINE 


NUMBER 

OF    PUPILS 

PER  CENT 

OF  PUPILS 

State  and  year 

Pupils 
examined 

Defective 

Defective 

Defective 

Defective 

in  vision 

in  hearing 

in  vision 

in  bearing 

Massachusetts 

1907      . 

432,464 

96,607 

27.387 

22.3 

6.3 

1908      . 

437.435 

81,158 

22,601 

18.6 

5-2 

1909      . 

441,463 

73.129 

20,167 

16.6 

4.6 

1910 

454,058 

71,902 

17.329 

15.8 

3.8 

Connecticut,  1908  . 

142,554 

12,217 

8.6 

Maine,  1911     . 

87,954 

11,145 

4,075 

12.7 

4.6 

RECORDS 

Individual  records  are  a  most  important  feature  of  a  system 
of  physical  examinations.  General  information  about  the  health 
of  the  pupils  as  a  whole  will  not  do;  there  must  be  a  complete 
individual  record  for  each  child.  The  record  card  or  blank  must 
have  spaces  for  entering  the  results  of  subsequent  examinations 
as  well  as  the  initial  one.  If  the  work  is  to  be  of  real  practical 
value,  there  must  be  the  closest  connection  between  the  records  of 
the  physical  examinations  and  those  of  the  class  room. 

Three  classes  of  forms  are  essential.  In  the  first  place,  there 
must  be  a  system  for  notifying  the  parent  of  the  results  of  the 
physical  examination  of  the  child.  Forms  of  this  sort  are  con- 
sidered in  Chapter  VI  entitled,  Making  Medical  Inspection 
Effective.*  In  the  second  place,  there  is  the  individual  record  for 
each  child.  To  be  effective,  this  record  must  be  an  integral  part 
of  the  child's  educational  accounting  and  must  be  always  available, 

*  See  p.  72  ff . 
52 


>> 

u 


PHYSICAL   EXAMINATIONS 

constantly  kept  up  to  date,  and  frequently  referred  to  as  an  aid 
in  reaching  decisions  affecting  the  child's  welfare.  It  does  no 
good  to  have  a  record  on  a  card  filed  away  in  the  principal's  office 
or  in  the  office  of  the  board  of  health,  to  the  effect  that  Willie 
is  stone  deaf  in  the  right  ear,  if  the  teacher  knows  nothing  of  his 
defect  and  still  has  Willie  seated  in  the  back  left-hand  corner  of  the 
room.  Moreover,  the  records  must  follow  the  child  from  room  to 
room  and,  in  case  of  transfer,  from  school  to  school,  for  otherwise 
much  of  the  information  obtained  is  soon  rendered  useless. 

These  are  some  of  the  reasons  why  systems  for  conducting 
physical  examinations  constitute  entirely  different  problems  from 
systems  of  medical  inspection  which  aim  only  at  the  detection  of 
cases  of  contagious  disease.  The  latter  sort  of  work  can  quite 
satisfactorily  be  handled  by  representatives  of  the  board  of  health, 
while  systems  for  conducting  physical  examinations,  if  they  are 
permanently  to  succeed,  must  have  the  active  co-operation  of  the 
educational  authorities. 

Few  cities  have  developed  record  systems  which  satisfactorily 
fulfill  the  requirements  outlined  above.  A  fairly  well  devised  card 
for  keeping  the  individual  record  of  physical  examinations  is  that 
in  use  in  the  Chicago  schools.  It  is  reproduced  on  page  54.  This 
card  measures  4x6  inches  and  has  spaces  which  provide  for  eight 
annual  examinations.  On  the  reverse  side  are  spaces  for  "diag- 
nosis" and  "treatment  received"  with  dates. 

A  somewhat  more  complete  record  is  the  one  kept  in  the 
public  schools  of  Pasadena,  California.  This  card,  shown  on  page 
55,  has  the  added  advantage  of  providing  spaces  for  the  recording 
of  data  by  the  teacher  as  well  as  by  the  physician.  This  feature 
insures  the  intimate  interest  of  the  class  room  teacher  in  the  work 
and  in  the  records.  The  reverse  of  the  Pasadena  card  has  spaces 
designed  to  record  the  dates  of  physical  examinations,  and  the 
dates  and  results  of  visits  made  by  the  school  nurse  to  the  pupil's 
home. 

A  still  more  complete  record  is  called  for  by  the  card  used  in 
Berkeley,  California,  which  provides  on  its  face  for  the  data  of  the 
physical  examinations,  and  on  its  reverse  has  spaces  for  keeping 
the  scholarship  record.  This  card,  face  and  reverse,  is  given  on 
pages  56  and  57. 

53 


INDIVIDUAL  RECORD  CARD.    PHYSICAL  EXAMINATIONS,  CHICAGO,  ILL. 


DEPARTMENT  OF  HEALTH—  CITY  OF  CHICAGO 

NAME  ADDRESS 

PHYSICAL  RECORD 
SEX                          AGE                    BIRTHPLACE 

NATIONALITY  OF  FATHER                                       MOTHER 

No.  OF  CHILDREN  IN  FAMILY                   His.  OF  MEASLES 

DIPH.                    PERTUSSIS                   PNEU.                   SCARLET  FEVER 

SCHOOL                                                                                    VACCINATED? 

DATE  IST  EXAM.                                      19 

O  PLACED  IN  SQUARE  MEANS  ABSENCE  OF  DEFECTS.            X  DENOTES  DEFECTS 

i  GRADE 

i 

2 

3 

4 

5 

6 

7 

8 

2  YEARS  IN  SCHOOL 

3  REVACCINATION 

4  DISEASES  DURING  YEAR 

S  DATEOFPHYS.  EXAM. 

6  HEIGHT 

7  WEIGHT 

8  NUTRITION 

9  ANEMIA 

10  ENLARGED  GLANDS 

it  GOITRE 

12  NERVOUS  DISEASES 

13  CARDIAC  DISEASE 

14  PULMONARY  " 

15  SKIN 

16  DEFECT  ORTHOPEDIC 

17  RACHITIC  TYPE 

1  8  DEFECT  OF  VISION 

19  OTHER  DISEASES  OF  EYE 

20  DEFECT  OF  HEARING 

21  DISCHARGING  EAR 

DEFECT  OF  NASAL 
22    BREATHING 

23  DEFECT  OF  PALATE 

24        "       "    TEETH 

25  HYPERTROPHIED  TONSILS 

26  ADENOIDS 

27  MENTALITY 

28  CONDUCT 

29  EFFORT 

30  PROFICIENCY 

31  WASTREATM'T  ADVISED 

! 

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57 


MEDICAL   INSPECTION    OF    SCHOOLS 

Reference  has  been  made  to  the  three  types  of  records  which 
must  be  kept:  the  first  is  the  card  of  notification  to  the  parents, 
the  second  is  the  individual  physical  record,  the  third  is  the  blank 
on  which  the  school  physician  periodically  records  the  numbers  and 
results  of  the  physical  examinations  made  by  him.  This  third 
form  is  in  nature  a  recapitulation  of  the  individual  records  and 
must  be  designed  so  that  the  results  of  large  numbers  of  individual 
records  may  be  combined  on  it  and  presented  in  report  form. 


RECORDS  OF  COMBINATIONS  OF  DEFECTS 

Reference  to  the  tables  which  have  been  presented,  giving 
the  results  of  physical  examinations,*  shows  that  the  total  number 
of  defects  reported  is  considerably  in  excess  of  the  number  of 
defective  children  found.  This  is  because  one  child  frequently 
suffers  from  several  sorts  of  defects. 

For  example,  the  child  who  has  seriously  hypertrophied 
tonsils  commonly  suffers  from  adenoids,  and  when  he  has  both  of 
these  defects  to  a  marked  degree,  he  almost  certainly  has  in  addi- 
tion seriously  defective  teeth.  Plainly,  the  value  of  the  records 
would  be  greatly  enhanced  if  there  were  some  method  for  recording 
not  only  the  existence  of  separate  defects,  but  the  combinations 
in  which  they  are  found.  Only  through  making  and  studying  such 
records  can  trustworthy  conclusions  be  formed  as  to  the  degree  to 
which  different  defects  are  to  be  rated  as  both  causes  and  effects 
of  one  another. 

The  first  requisite  of  a  plan  for  recording  combinations  is 
that  it  be  simple;  and  this  means  that  it  must  be  restricted  to  a  few 
of  the  more  important  defects.  The  reason  for  this  is  that  the 
number  of  possible  combinations  increases  with  enormous  rapidity 
with  each  increase  in  the  number  of  defects  considered.  Thus,  if 
we  are  considering  two  defects,  A  and  B,  there  are  four  possible 
combinations.  First,  the  child  may  have  neither  defect;  second, 
he  may  have  A;  third,  he  may  have  B;  and  in  the  fourth  place,  he 
may  have  both  A  and  B.  When  we  consider  three  defects,  there 
are  eight  possible  combinations;  and  when  the  number  is  increased 
to  four,  the  combinations  increase  to  16.  Proceeding  at  the  same 
*  See  Tables  1 1  and  12,  p.  38. 

58 


PHYSICAL    EXAMINATIONS 

ratio,  there  are  32  possible  combinations  of  five  defects,  and  64 
of  six  defects. 

These  figures  will  suffice  to  support  the  statement  that  any 
plan  for  recording  combinations  of  defects  must  provide  for 
recording  data  pertaining  only  to  the  more  important  sorts  of 
defectiveness.  Fortunately,  this  is  made  possible  by  existing 
conditions.  We  have  seen  from  the  data  presented  that  defects 
of  teeth,  eyes,  throat,  and  nose  constitute  more  than  four-fifths 
of  all  the  cases  of  physical  defectiveness. 

The  problem,  then,  is  to  develop  a  system  for  recording 
the  combinations  of  these  defects.  This  can  be  done  simply  and 
easily  by  making  provision  on  the  individual  physical  record  card 
of  each  child  for  recording  the  presence  of  any  of  these  defects  — 
or  any  combination  of  them  —  by  printing  the  four  words  Teeth, 
Throat,  Eyes,  Nose,  at  the  four  corners  of  a  square  as  follows: 

Teeth  Throat 

• 

Eyes  Nose 

If  the  examination  shows  that  the  child  has  defective 
teeth,  the  fact  is  recorded  by  drawing  a  line  from  the  word 
"Teeth"  to  the  dot  in  the  middle  of  the  square  as  follows: 

Teeth.         Throat 

Eyes  Nose 

In  a  similar  way  this  device  may  be  used  to  record  any  one 
of  the  1  6  possible  combinations  of  the  four  defects.  These  possible 
uses  are  the  following: 

No  Defect  —  One  Possible  Combination 
Teeth  Throat 


Eyes  Nose 

59 


MEDICAL    INSPECTION    OF    SCHOOLS 

One  Defect  —  Four  Possible  Combinations 
Teeth  v          Throat  Teeth  Throat 

Eyes  Nose  Eyes  Nose 

Teeth  Throat  Teeth  Throat 

Eyes  Nose  Eyes          ^Nose 

Two  Defects  —  Six  Possible  Combinations 
Teeth.  Throat  Teeth          .Throat 

Eyes  Nose  Eyes         ^ 


Teeth          ^Throat  Teeth  v         Throat 


\ 


Eyes  '          Nose  Eyes '        NNose 

Teeth  Throat  Teeth  Throat 

Eyes  Nose  Eyes  *     ^Nose 

Three  Defects — Four  Possible  Combinations 
Teeth  Throat  Teeth  Throat 

Eyes  -      ^Nose  Eyes        ^  Nose 

Teeth  Throat  Teeth          .Throat 

Eyes  *          Nose  Eyes        ^  Nose 

Four  Defects — One  Possible  Combination 
Teeth  Throat 

Eyes  '     ^  Nose 
60 


PHYSICAL    EXAMINATIONS 

If  the  recapitulation  blank  on  which  the  medical  inspector 
reports  his  work  by  schools  for  a  term  or  year  is  furnished  with 
spaces  for  recording  these  combinations,  the  data  from  the  individ- 
ual cards  can  be  rapidly  and  easily  transferred.  This  makes  it 
easy  to  bring  together  data  for  any  part  of  the  system  for  study 
and  report.  The  scheme  also  has  the  advantage  of  showing 
automatically  the  number  of  pupils  not  defective  and  those 
suffering  respectively  from  one,  two,  three,  or  four  of  these  impor- 
tant defects.  Moreover,  by  means  of  this  scheme  it  is  easy  to 
discover  the  total  number  of  cases  of  defective  teeth,  eyes,  etc., 
both  singly  and  in  combinations.  Most  important  of  all,  the  plan 
furnishes  valuable  material  for  discovering  causes  and  effects. 

SUMMARY. — Physical  examinations  aim  to  insure  for  each 
child  such  physical  and  mental  vitality  as  will  best  enable  him  to 
take  full  advantage  of  the  free  education  offered  by  the  state. 
There  is  a  mass  of  convincing  evidence  showing  that  a  large 
percentage  of  all  school  children  suffer  from  remediable  physical 
defects  which  can  be  prevented  or  cured  if  detected  early  in  life. 

In  the  average  city  school  system,  about  65  per  cent  of  the 
children  have  physical  defects  serious  enough  to  warrant  treatment 
by  a  physician,  oculist,  or  dentist.  Nearly  85  per  cent  of  all  these 
defects  are  those  of  teeth,  throat,  eyes,  and  nose.  Complete 
examinations  require  from  three  to  ten  minutes  per  child.  Eleven 
American  states  have  laws  providing  for  the  physical  examination 
of  school  children. 


61 


CHAPTER  V 
THE  SCHOOL  NURSE 

THE  value  of  the  school  nurse  is  the  one  feature  of  medical 
inspection  of  schools  about  which  there  is  no  division  of 
opinion.    Her  services  have  abundantly  demonstrated  their 
utility,  and  her  employment  has  quite  passed  the  experimental 
stage.     The  introduction  of  the  trained  nurse  into  the  service  of 
education  has  been  rapid,  and  few  school  innovations  have  met 
with  such  widespread  support  and  unqualified  approval. 

The  reason  for  this  is  that  the  school  nurse  supplies  the 
motive  force  which  makes  medical  inspection  effective.  The 
school  physician's  discovery  of  defects  and  diseases  is  of  little  use 
if  the  result  is  only  the  entering  of  the  fact  on  the  record  card  or  the 
exclusion  of  the  child  from  school.  The  notice  sent  to  parents 
telling  of  the  child's  condition  and  advising  that  the  family  physi- 
cian be  consulted,  represents  wasted  effort  if  the  parents  fail  to 
realize  the  import  of  the  notification  or  if  there  be  no  family 
physician  to  consult.  The  nurse  converts  these  ineffective  lost 
motions  into  efficient  functioning  by  assisting  the  physician  in  his 
examinations,  personally  following  up  the  cases  to  insure  remedial 
action,  and  educating  teachers,  children,  and  parents  in  practical 
applied  hygiene. 

HISTORY  AND  PRESENT  STATUS 

School  nursing  had  its  inception  in  London  in  1894  when  the 
managers  of  a  school  in  a  very  poor  section  asked  a  district  nurse 
to  visit  the  school  to  do  what  she  could  to  promote  the  physical 
welfare  of  the  children.  This  beginning  was  followed  in  1898  by 
the  formation  of  a  volunteer  "School  Nurses'  Society"  with  the 
object  of  supplying  visiting  nurses  to  elementary  schools  in  four 

62 


K5. 


THE    SCHOOL   NURSE 

districts.    Work  was  begun  by  the  appointment  of  three  nurses, 
each  of  whom  had  four  schools  under  her  care. 

These  early  experiments  demonstrated  so  conclusively  the 
value  of  the  nurse's  services  that  in  1904  the  system  was  taken  over 
by  the  city  and  supported  by  municipal  funds.  The  number  of 
nurses  was  greatly  increased  and  the  work  rapidly  spread  to  other 
towns  and  cities. 

From  the  work  in  London  came  the  suggestion  for  a  nursing 
staff  in  the  schools  of  New  York.  Medical  inspection  had  been 
begun  in  the  schools  of  New  York  in  1897,  and  by  1902  the  number 
of  children  excluded  for  infectious  or  contagious  diseases  had  risen 
to  alarming  proportions.  During  the  latter  year  there  were 
nearly  18,000  such  exclusions,  and  many  schools  were  so  depleted 
that  almost  half  of  their  children  were  absent.  This  condition 
aroused  serious  protest  on  the  part  of  parents  and  teachers. 

At  this  juncture  Lillian  D.  Wald,  head  worker  of  the  Henry 
Street  Nurses'  Settlement,  called  attention  to  the  work  of  the 
school  nurses  in  England  and  offered  to  lend  the  services  of  one 
of  her  staff  for  an  experimental  demonstration  of  one  month. 
This  first  American  school  nurse  was  Lina  L.  Rogers.    As  in  t 
England,  so  in  America,  it  required  only  one  demonstration  to/ 
convince  the   public   of   the  value  of  the   school   nurse.     Her' 
services  were  so  valuable  that  the  educational  authorities,  the 
board  of  health,  and  the  public  were  at  once  converted  to  the 
new  idea,  and  the  movement  for  the  employment  of  nurses  in 
connection  with  systems  of  medical  inspection  rapidly  spread  to 
other  cities.     By  means  of  work  in  the  schools  and  in  the  home 
minor  ailments  were  promptly  cared  for,  and  the  number  of  exclu- 
sions greatly  reduced. 

According  to  the  investigation  conducted  by  the  Russell 
Sage  Foundation  in  1911,  there  were  at  the  beginning  of  that  year 
415  school  nurses  employed  in  102  municipalities  in  the  United 
States,  and  375  of  these,  or  90  per  cent,  were  in  the  North  Atlantic 
or  North  Central  states.  About  one-quarter  of  the  cities  hav- 
ing systems  of  medical  inspection  employed  school  nurses,  and 
the  number  is  rapidly  increasing.  Again,  there  was  a  consid- 
erable number  of  cities  where  nurses  were  employed,  but  no  physi- 
cians. 

63 


MEDICAL  INSPECTION  OF  SCHOOLS 

THE  NURSE  IN  AMERICAN  SCHOOL  SYSTEMS 

DUTIES 

The  functions  of  the  school  nurse  are  most  varied  in  different 
communities  and  include  duties  which  range  from  the  reporting 
of  cases  of  truancy  to  diagnosing  contagious  diseases — two  extremes, 
neither  of  which  properly  falls  within  the  purview  of  her  work. 
In  general  her  duties  may  be  concisely  summarized  as  follows: 

1.  In  the  school: 

(a)  Making  routine  examinations  of  children  to  detect  those  cases 
which  should  be  referred  to  the  school  physician. 

(b)  Assisting  the  physician  in  making  physical  examinations  and 
recording  results. 

(c)  Acting  in  emergency  cases  such  as  caring  for  accidents,  ban- 
daging cuts,  removing  splinters,  caring  for  cases  of  fainting,  convulsions, 
and  the  like. 

2.  In  the  home: 

(a)  Explaining  to  parents  the  significance  of  the  notices  sent  by 
the  school  physicians  concerning  the  condition  of  their  children  and  aid- 
ing the  parents  in  securing  remedial  action. 

(b)  Instructing  and  educating  parents  in  the  practices  of.  applied 
hygiene. 

3.  In  the  clinic: 

(a)  Assisting  the  physicians  in  treatments  and  operations. 

(b)  Leading  the  children  to  view  the  proceedings  of  the  clinic  as 
diverting  experiences  rather  than  terrifying  ordeals. 

QUALIFICATIONS 

The  history  of  school  nursing  shows  its  continual  extension 
into  wider  and  wider  fields,  and  its  constantly  increasing  demands 
for  unusual  qualifications  on  the  part  of  the  workers.  In  a  techni- 
cal sense  the  work  is  not  really  nursing  at  all,  but  it  calls  for  a 
skill  and  knowledge  acquired  only  in  the  training  schools  for  nurses, 
and  demands  in  addition  qualifications  which  can  at  present  be 
secured  only  in  the  school  of  experience. 

It  is  a  safe  rule  that  no  school  nurse  should  be  employed  who 
is  not  a  graduate  of  a  training  school  of  recognized  high  standing. 

64 


THE    SCHOOL   NURSE 

In  addition,  she  should  have  had  special  experience  with  children, 
of  the  sort  that  she  would  gain  through  serving  on  the  staff  of  a 
children's  hospital. 

In  judging  the  qualifications  of  candidates,  success  in  dis-\ 
trict  work  should  be  given  preference  over  length  of  experience./ 
The  successful  school  nurse  is,  first  of  all,  an  intermediary  between 
physicians,  teachers,  parents,  and  children.     Permanent  success 
requires  tact  above  all  other  qualifications.     No  single  phra; 
in  our  language  adequately  describes  the  qualification  or  abiliti 
referred  to.     It  is  that  attribute  which  the  Spaniards  designat< 
as  the  "don  de  gentes,"  which,  freely  translated,  means  the  ^gil 
of  getting  along  with  people/' 

Among  other  necessary  qualifications  may  be  mentioned 
activity,  and  ability  to  carry  a  large  amount  of  work  without 
worry.  Any  tendency  to  gossip  should  constitute  sufficient  cause 
for  immediate  disqualification. 

EFFECTIVENESS  OF  THE  NURSE'S  WORK 
Reference  has  been  made  to  the  value  of  the  school  nurse's 
work  in  reducing  the  number  of  exclusions  on  account  of  contagious 
and  infectious  diseases.  How  this  operates  in  practice  is  shown  by 
the  experience  of  New  York  City  before  and  after  the  organization 
of  the  corps  of  school  nurses.  In  the  system  prevailing  up  to  1902 
all  cases  of  contagious  and  infectious  diseases  were  excluded  by  the 
physician.  If  this  system  had  continued  in  force  the  number  of 
exclusions  in  1911  would  have  reached  a  grand  total  of  253,738. 
This  number  is  so  great  in  proportion  to  the  total  membership  of 
the  schools  that  had  all  these  children  been  excluded  the  entire 
school  system  would  have  been  seriously  disorganized.  The 
actual  number  of  exclusions  during  191 1  amounted  to  8,154,  or  a 
little  more  than  3  per  cent  of  the  number  of  cases  of  contagious 
diseases.  This  means  that  in  the  experience  of  New  York  City, 
through  the  employment  of  school  nurses  exclusions  from  school 
had  been  reduced  to  something  like  one-thirtieth  of  their  forme^ 
proportions. 

While  a  review  of  reports  on  medical  inspection  in  American 
cities  shows  that  superintendents  and  medical  inspectors  have 
abundantly  endorsed  the  work  of  school  nurses,  it  is  only  rarely 

5  65 


MEDICAL    INSPECTION    OF    SCHOOLS 

that  data  are  found  giving  any  sort  of  measure  of  the  value  of  their 
services.  Almost  the  only  direct  comparison  between  results 
accomplished  with  and  without  the  co-operation  of  the  nurses 
comes  from  the  city  of  Philadelphia.  Data  bearing  on  the  problem 
were  presented  by  Dr.  Samuel  W.  Newmayer  of  that  city  in  a  paper 
entitled  Evidence  that  the  School  Nurse  Pays,  printed  in  the 
proceedings  of  the  Fifth  Annual  Congress  of  the  American  School 
Hygiene  Association. 

The  first  set  of  data  presented  by  Dr.  Newmayer  shows  the 
number  and  per  cent  of  recommendations  acted  upon  in  four 
schools  where  a  nurse  was  at  work  as  compared  with  the  number 
acted  upon  in  four  other  schools  where  the  medical  inspector  was 
unaided  by  a  nurse.  This  comparison  is  shown  in  Table  1 7. 


TABLE  17. — RESULTS  OBTAINED  BY  MEDICAL  INSPECTORS  AIDED  AND 

NOT   AIDED    BY    SCHOOL   NURSES.       EIGHT   SCHOOLS, 

PHILADELPHIA,    IQIO 


RESULTS  WITH  NURSE'S  AID 

RESULTS  WITHOUT  NURSE'S  AID 

*9 

| 

a 

K 

a 

•*•* 

•£» 

•S 

•S   s» 

8 

<3 

S 

53 

<3    S 

2 

School 

1 

s  s 

li 
84 

<o   «» 
k. 

School 

1 

1* 
h 

g  ts 

H 

v. 

1 

O    <3 

a. 

s 

2  Q 

tt. 

ftj 

Qtf 

04 

04 

A 

324 

262 

81 

E 

283 

83 

29 

B         .       .       . 

445 

434 

98 

F       .       .       . 

582 

152 

26 

C        .       .       . 

320 

282 

88 

G       .       .       . 

441 

94 

21 

D        .       .       . 

264 

226 

86 

H      .       .       . 

474 

'9 

Total      . 

,353 

1,204 

89 

Total    . 

1,780 

420 

24 

A  comparison  of  the  percentage  figures  shows  that  in  the 
four  schools  where  the  inspector  was  aided  by  a  nurse  89  per  cent 
of  the  recommendations  were  acted  upon,  whereas  in  the  four  other 
schools,  where  the  medical  inspector  worked  alone,  only  24  per 
cent  of  the  recommendations  resulted  in  action. 

Dr.  Newmayer's  second  series  of  data  contrasted  two  sets 

66 


THE    SCHOOL   NURSE 


of  results  with  respect  to  four  specified  kinds  of  physical  defects. 
The  data  are  presented  in  Table  18. 

TABLE  l8. — RESULTS  OBTAINED  BY  MEDICAL  INSPECTORS  AIDED  AND 
NOT  AIDED  BY  SCHOOL  NURSES.     PHILADELPHIA,  1910 


Defect 

RESULTS  WITH  NURSE'S 

AID 

RESULTS  WITHOUT  NURSE'S 

AID 

Number 
of  cases 

Cases 
treated 

Per  cent 
treated 

Number 
of  cases 

Cases 
treated 

Per  cent 
treated 

Vision  .... 
Tonsils 
Adenoids 
Teeth    .... 

441 
104 
62 
150 

355 
68 

45 
138 

80 
65 

73 
92 

272 
338 
36 
152 

r 
62 

5 
31 

26 
18 
14 

20 

Total 

757 

606 

80 

798 

1  68 

21 

A  comparison  of  the  figures  in  the  percentage  columns  shows 
that  where  the  inspector  was  aided  by  a  nurse,  80  per  cent  of  the  j 
cases  received  treatment  as  contrasted  with  only  2 1  per  cent  where/ 
he  was  without  such  aid.    The  investigation  covered  the  same 
period  of  time  in  the  two  cases  and  the  defects  existed  among  704 
children  in  the  school  where  the  inspector  was  aided  by  a  nurse, 
and  among  75 1  children  where  he  was  not  aided  by  a  nurse. 

While  the  comparisons  presented  in  the  foregoing  tables 
constitute  an  impressive  argument  in  favor  of  utilizing  the  services 
of  a  school  nurse  to  increase  the  effectiveness  of  medical  inspection, 
they  must  not  be  accepted  as  giving  a  true  measure  of  the  value  of 
such  services.  We  must  not  interpret  them  as  meaning — as  the 
figures  would  seem  to  show — that  medical  inspection  with  a  nurse 
is  three  or  four  times  as  effective  as  medical  inspection  without  a 
nurse.  In  the  case  of  the  per  cent  shown  in  the  first  table  we  are 
not  certain  as  to  the  character  of  the  "results"  reported,  and  in 
studying  both  comparisons  it  must  be  borne  in  mind  that  they 
represent  reports  of  special  studies  made  with  the  object  of  demon- 
strating the  effectiveness  of  the  nurse's  work.  Nevertheless,  the 
comparisons  are  of  value  in  showing  that  the  effectiveness  of  medi- 
cal inspection  is  definitely  and  distinctly  enhanced  when  the  work 
of  the  school  physician  is  supplemented  by  that  of  the  school  nurse. 

67 


MEDICAL  INSPECTION  OF  SCHOOLS 

PROPORTION  OF  NURSES  TO  PUPILS 

Experience  in  New  York,  Philadelphia,  and  other  large 
cities  has  shown  that  in  the  congested  districts  a  nurse  should  be 
^provided  for  every  3,000  or  4,000  pupils.  With  this  number  of 
pupils  the  nurses  can  do  effective  and  efficient  home  visiting  as 
well  as  the  work  of  routine  inspection  in  the  schools.  In  cities 
of  from  20,000  to  30,000  inhabitants  with  a  public  school  enroll- 
ment of  3,000  to  5,000  the  services  of  one  nurse  will  be  found 
adequate,  providing  the  schools  are  reasonably  near  together. 

It  must  be  remembered  in  this  connection  that  much  depends 
on  the  social  status  of  the  children.  The  records  of  medical  in- 
spection in  great  cities  show  that  many  sorts  of  physical  defects 
vary  in  more  or  less  direct  proportion  with  the  degree  of  poverty 
in  the  homes  of  the  children.  Among  such  defects  are  enlarged 
tonsils,  defective  nasal  breathing,  defective  hearing,  decayed 
teeth,  skin  diseases,  vermin,  and  above  all,  malnutrition.  In  the 
poorer  sections  of  cities  and  in  quarters  largely  peopled  with  recent 
immigrants  the  prevalence  of  these  conditions  will  require  the 
appointment  of  more  nurses  if  the  work  is  to  be  done  effectively. 
With  conditions  as  they  now  exist  in  such  sections  of  our  greater 
cities,  one  nurse  for  each  2,000  children  or  even  one  for  each  1,500 
is  none  too  many. 

RULES  FOR  NURSES 

The  following  set  of  rules  issued  by  the  board  of  education 
of  Newark,  New  Jersey,  embodies  most  of  the  features  that 
characterize  the  best  practice  in  connection  with  the  rules  and 
instructions  laid  down  for  the  guidance  of  school  nurses.  With 
such  modifications  as  local  conditions  demand,  they  will  be  found 
satisfactory  for  use  in  most  communities. 

Rule  i.  Nurses  shall  at  all  times  be  under  the  direction  of  the 
Supervisor  of  Medical  Inspection. 

Rule  2.  Applicants  for  the  position  of  school  nurse  shall  submit 
to  an  oral  and  written  examination  and  also  to  a  physical  examination 
by  the  Supervisor  of  Medical  Inspection.  All  applicants  must  hold  a 
certificate  of  graduation  from  an  approved  training  school  for  nurses, 
having  a  course  of  not  less  than  two  years. 

Rule  3.  The  salary  of  each  nurse  shall  be  for  the  first  year,  $720; 

68 


THE    SCHOOL   NURSE 

second  year,  $780;  third  year,  $840;  fourth  year,  $900,  the  maximum; 
in  twelve  monthly  payments.  In  addition,  each  nurse  shall  be  supplied 
with  carfare  at  the  expense  of  the  Board  of  Education  and  an  outfit, 
consisting  of  a  bag  and  supplies  for  treating  her  cases.  These  supplies 
shall  be  obtained  on  order  from  the  Department  of  Medical  Inspection. 

Rule  4.  Each  nurse  shall  devote  her  entire  time  to  the  school 
work  during  the  hours  of  service,  which  shall  be  from  eight  a.  m.  to 
twelve  noon,  and  from  one  p.  m.  to  five  p.  m.  on  all  week  days  except 
Saturday,  when  the  hours  of  service  shall  be  from  eight  a.  m.  to  twelve 
noon,  and  at  other  times  if  required  by  the  Supervisor  of  Medical  In- 
spection in  special  cases.  Nurses  shall  report  to  the  office  of  the  Super- 
visor of  Medical  Inspection  each  morning  at  eight  a.  m.  for  instruction, 
and  shall  attend  meetings  with  the  Supervisor  of  Medical  Inspection  at 
his  call.  A  daily  report  shall  be  made  out  by  each  nurse  on  forms  sup- 
plied by  the  department  and  filed  in  the  oifice  of  the  Supervisor  of  Medical 
Inspection.  Each  nurse  shall,  on  visiting  a  school,  register  her  name,  time 
of  arrival  and  departure,  in  the  attendance  book  in  the  principal's  office. 

Rule  5.  Nurses  shall  perform  class  room  inspection  once  a  month, 
or  oftener  if  directed  by  the  Supervisor  of  Medical  Inspection.  Nurses 
shall  refer  all  cases  of  suspected  disease  or  defect,  except  pediculosis,  to 
the  medical  inspector  for  his  opinion  as  to  what  shall  be  done.  Where 
contagious  disease  is  suspected,  and  the  doctor  is  not  in  the  school,  the 
pupil  shall  be  excluded.  The  name,  age,  address,  and  school  of  pupil 
shall  be  reported  immediately  to  the  office  of  the  Supervisor  of  Medical 
Inspection.  All  other  diseases  and  defects  which  are  not  contagious 
shall  be  brought  to  the  notice  of  the  medical  inspector  as  soon  as  possible. 

Rule  6.  The  nurse  shall  have  entire  charge  of  all  cases  of  pedicu- 
losis and  uncleanliness. 

Rule  7.  The  diseases  to  be  treated  by  the  nurse  are  as  follows: 
Ringworm,  scabies,  favus,  impetigo,  molluscum  contagiosum,  conjuncti- 
vitis, infected  wounds,  contusions  and  uncleanliness.  No  case  of  the 
above  diseases  shall  be  treated  by  a  nurse  without  the  diagnosis  being 
confirmed  by  the  medical  inspector  of  the  school  which  the  pupil  attends, 
and  whenever  possible,  with  the  parents'  consent.  A  record  shall  be  kept 
of  each  pupil  when  placed  under  treatment  by  the  nurse  and  the  dates 
of  subsequent  treatments  noted  on  forms  supplied  by  the  Board  of  Ed- 
ucation. 

Rule  8.  It  shall  be  the  duty  of  the  nurse  to  visit  the  homes  in 
special  cases,  for  the  purpose  of  interviewing  and  instructing  the  parents 
or  guardians.  These  visits  shall  be  made  before  or  after  school  hours 
and  on  Saturdays. 

69 


MEDICAL   INSPECTION    OF    SCHOOLS 

Cases  to  be  visited  by  the  nurse  at  home  are 

(a)  Flagrant    cases   of   pediculosis.     The  nurse  shall  show  the 
mother  how  to  treat  the  conditions  and  encourage  persistence. 

(b)  Excluded  cases  that  do  not  return  at  the  appointed  time. 

(c)  The  nurse  shall  call  at  the  homes  of  any  children  whose  par- 
ents have  refused  or  neglected  to  comply  with  the  request  of  the  medical 
inspector  or  have  not  given  a  satisfactory  reason  for  not  doing  so.     At 
this  time  the  nurse  shall  urge  upon  the  parent  the  need  for  treatment 
and,  if  necessary,  demonstrate  how  it  shall  be  done. 

Rule  9.  Practical  talks  on  personal  hygiene  and  home  hygiene 
shall  be  given  by  each  nurse  to  the  pupils  at  such  times  as  the  Supervisor 
of  Medical  Inspection  shall  specify,  but  not  to  interfere  with  the  ordinary 
routine  of  the  school. 

Rule  10.  Each  nurse  shall  receive  one  month's  vacation  during 
the  interval  between  the  closing  of  the  school  year  in  June,  and  the  re- 
opening of  the  schools  in  September,  the  time  of  vacation  to  be  designated 
and  assigned  by  the  Supervisor  of  Medical  Inspection. 

Rule  1 1 .  School  nurses  shall  be  appointed  to  serve  for  a  term  of 
one  year,  extending  from  February  ist  to  January  3ist.  In  case  a  va- 
cancy occurs,  same  shall  be  filled  for  the  unexpired  term  only. 

SALARIES 

The  salaries  of  school  nurses  in  American  municipalities 
range  from  $500  to  $1,500  per  annum.  The  study  made  in  191 1 
showed  that  the  salaries  of  nurses  were  distributed  as  shown  in 
the  following  table : 

TABLE  19. — SALARIES  OF  NURSES  IN  IO6  AMERICAN  MUNICIPALITIES 


Salary 

Number  of  cities  where  nurses 
received  salary  indicated 

No  salary         .               .... 

$2OI-$3OO           .                     .... 

$40i-$5oo        .               .... 
$50i-$6oo        .               .... 
$6oi-$yoo        .               .... 
#70i-#8oo        .               .... 
$8oi-$9oo        

21 
2 

I 
21 

I? 
24 
I  c 

$90i-$iooo      
$iooi-$i  500    
Fees  according  to  service 

2 
2- 
I 

Total         

1  06 

70 


THE    SCHOOL  NURSE 

The  table  shows  that  there  are  more  cities  paying  their 
school  nurses  from  $70 1  to  $800  per  annum  than  there  are  paying  any 
other  salary,  but  the  average  salary  would  be  about  $700  per  year. 
Where  the  nurses  render  services  without  cost  to  the  municipality 
their  salaries  are  paid  by  some  other  organization,  and  in  the  cases 
where  the  salary  is  between  $200  and  $300  the  payment  is  made  in 
return  for  only  a  part  of  the  nurse's  time.  In  some  cases  these 
salary  figures  represent  remuneration  for  twelve  months'  service, 
and  in  other  cases  for  only  nine  or  ten  months. 

It  is  a  safe  rule  that  no  municipality  should  expect  to  secure 
the  services  of  competent  women  of  the  right  type  for  less  than  $75 
per  month.  In  addition,  provision  should  be  made  for  increases 
based  on  satisfactory  services  and  higher  salaries  for  those  doing 
supervisory  work. 

SUMMARY. — To  sum  up  the  case  for  the  school  nurse:  She 
is  the  teacher  of  the  parents,  the  pupils,  the  teachers,  and  the 
family  in  applied  practical  hygiene.  Her  work  prevents  loss  of 
time  on  the  part  of  the  pupils  and  vastly  reduces  the  number  of 
exclusions  for  contagious  diseases.  She  cures  minor  ailments  in 
the  school  and  clinic  and  furnishes  efficient  aid  in  emergencies. 
She  gives  practical  demonstrations  in  the  home  of  required  treat- 
ments, often  discovering  there  the  source  of  the  trouble,  which, 
if  undiscovered,  would  render  useless  the  work  of  the  medical 
inspector  in  the  school.  The  school  nurse  is  the  most  efficient 
possible  link  between  the  school  and  the  home.  Her  work  is 
immensely  important  in  its  direct  results  and  far-reaching  in  its 
indirect  influences.  Among  foreign  populations  she  is  a  very  potent 
force  for  Americanization. 


CHAPTER  VI 
MAKING  MEDICAL  INSPECTION  EFFECTIVE 

MEDICAL    inspection   came   into    being  when    educators 
awoke  to  a  realizing  sense  of  the  intimate  relationship 
existing  between   physical  vigor  and  mental  efficiency. 
Physical  examinations  have  become  the  most  important  feature 
of  medical  inspection  because  of  the  great  mass  of  data  showing 
that  a  large  proportion  of  all  school  children  suffer  from  entirely 
remediable  physical  defects,  the  very  existence  of  which  was 
formerly  unsuspected  by  the  teachers,  by  the  parents,  and  by  the 
pupils  themselves. 

The  theory  underlying  the  conduct  of  physical  examinations, 
as  we  have  noted,  has  been  that  it  is  the  function  of  the  school 
medical  department  to  discover  these  defects  and  bring  their 
existence  to  the  attention  of  the  parents.  Wherever  inspection 
has  been  carried  on  for  any  considerable  time,  experience  has 
demonstrated  that  this  procedure  is  not  sufficient.  After  the  first 
interest  dies  down,  mere  notification  does  not  suffice  to  secure 
action  on  the  part  of  any  large  proportion  of  the  parents.  In 
order  that  the  work  may  be  effective,  the  cases  must  be  followed  up, 
the  parents  convinced  that  some  action  is  necessary,  and  the 
community  educated  up  to  a  new  standard  of  applied  hygiene. 


SECURING  PARENTS'  CO-OPERATION 

NOTIFICATIONS  OF  PARENTS 

In  the  simplest  systems  of  medical  inspection,  parents  are 
notified  of  defects  discovered  by  means  of  a  simple  card  advising 
that  the  child  be  taken  to  a  physician  for  treatment.  A  typical 
example  of  such  a  card  is  the  one  furnished  by  the  state  board  of 
education  of  Massachusetts. 

72 


MAKING   MEDICAL    INSPECTION    EFFECTIVE 
NOTICE  TO  PARENT  OR  GUARDIAN,  MASSACHUSETTS 


Commonwealth  of  Massachusetts 


NOTICE  TO  PARENT  OR  GUARDIAN 

IN  ACCORDANCE  WITH  CHAPTER  502  OF  THE  ACTS  OF  1906  YOU 
ARE  HEREBY  NOTIFIED  THAT 

HAS  BEEN  EXAMINED  BY  ME  AS  SCHOOL  PHYSICIAN  AND  FOUND 
TO  HAVE  SYMPTOMS  OF 

PLEASE  SECURE  COMPETENT  MEDICAL  ADVICE 
AT  ONCE 

SCHOOL  PHYSICIAN. 

....19 


When  systems  become  more  highly  developed,  it  is  found  that 
the  effectiveness  of  the  work  can  be  greatly  enhanced  by  sending 
the  notification  on  a  return  post  card  which  serves  the  purpose  of 
notifying  the  parent  of  the  condition  of  his  child,  making  a  brief 
statement  as  to  the  importance  of  the  case,  and  providing  a  con- 
venient means  whereby  the  physician  consulted  can  report  back 
to  the  school  authorities  what  action,  if  any,  he  has  taken  in  the 
case.  The  post  card  form  in  use  in  Birmingham,  Alabama,  shown 
on  page  74,  fulfills  these  three  objects  admirably. 

SECURING  PARENTS'  CONSENT 

In  many  cities  special  forms  are  used  on  which  parents  give 
written  consent  to  have  their  children  treated  at  the  school  clinics 
or  the  hospitals  working  in  co-operation  with  the  educational 
authorities.  A  typical  blank  of  this  type  is  the  form  reproduced 
on  page  75,  which  is  in  use  in  the  public  schools  of  St.  Louis. 

PARENTS  PRESENT  AT  EXAMINATIONS 

In  England  and  in  Germany  special  care  is  taken  to  have 
parents  present  during  the  examination  of  their  children  in  order 

73 


MEDICAL   INSPECTION    OF    SCHOOLS 

POST  CARD  NOTIFICATION  FORM,  BIRMINGHAM,  ALABAMA 
Present  this  Card  to  Physician.  Series  C— Form  i 

BOARD  OF  EDUCATION 

BIRMINGHAM,  ALA. 

School.  Date 191.... 

M 

We  have  reason  to  believe  that 

a  pupil  in  the  school,  is  in  need  of  medical  attention  for 

We  advise  that  you  consult  your 

family  physician,  or  the  Free  Dispensary  of  the  Hillman 
Hospital  (open  daily  at  12:00  o'clock,  noon). 

M.  D. 

MEDICAL  DIRECTOR. 


(OVER) 


TO  TH  F   PHYSICIAN'    In  order  to  complete  the  record  in  this  case,  you 
'   are  requested  to  kindly  state  the  result  of  your 

examination  and  to  mail  this  card.  Please  do  not  write  the  name  of  the  child,  as  this  card 
is  registered  by  number. 

The  child  presenting  this  card  is  found  to  suffer  from 


Treatment  has been  instituted. 

Date M.D. 

No.... 


TO  PARENTS: 

Experience  has  shown  that  a  large  percentage  of  school 
children  suffer  from  eye-strain,  throat  or  ear  disease,  or  other 
preventable  defects.  These  disorders  can  be  greatly  relieved 
or  prevented,  if  recognized  early,  but  if  allowed  to  persist  or 
grow  worse,  may  seriously  impair  the  child's  general  health 
and  mental  development.  Mental  backwardness  may  be 
traced  frequently  to  physical  defects. 

Such  diseases  may  be  readily  recognized  in  the  school 
room,  and  this  recognition  and  prevention  is  the  object  of 
the  Department  of  Medical  Inspection  in  the  schools. 
Respectfully,  J.  H.  PHILLIPS, 

Superintendent. 

74 


MAKING  MEDICAL  INSPECTION  EFFECTIVE 
PARENT'S  CONSENT  BLANK,  ST.  LOUIS,  MISSOURI 


FORM  II-Q 


ST.  LOUIS  PUBLIC  SCHOOLS. 

DEPARTMENT  OF  HYGIENE. 


PARENT'S  CONSENT  BLANK. 

St.  Louis, 

I  desire  and  hereby  authorize  that  my  child 

be  taken  by  the  school  nurse  to 

the  Free  Medical  Clinic  or  Free  Hospital  for  whatever  treat- 
ment, medicinal  or  surgical,  the    Doctors  in  charge  find 
necessary  to  improve  the  health  of  the  above  named  child. 
Respectfully, 


School  Nurse  Witness: 


that  their  sympathy  and  assistance  may  be  enlisted  and  held. 
This  purpose  is  expressed  in  the  memorandum  of  the  British 
board  of  education  as  follows: 

"Nor  must  the  influence  which  the  parent  can  exercise  by  ex- 
ample and  precept  be  neglected.  One  of  the  objects  of  the  new  legisla- 
tion is  to  stimulate  a  sense  of  duty  in  matters  affecting  health  in  the 
homes  of  the  people,  to  enlist  the  best  services  and  interests  of  the  parents, 

75 


MEDICAL    INSPECTION    OF    SCHOOLS 

and  to  educate  their  sense  of  responsibility  for  the  personal  hygiene"  of 
their  children.  The  increased  work  undertaken  by  the  state  for  the 
individual  will  mean  that  the  parents  have  not  to  do  less  for  themselves 
and  their  children,  but  more." 

In  the  attainment  of  this  purpose,  the  English  educational 
authorities  almost  invariably  attempt  to  have  either  the  parent 
or  guardian  of  the  child  present  during  the  first  examination. 
In  1909  the  percentage  of  parents  attending  inspections  varied 
from  13  to  90  in  different  localities.  In  more  than  half  of  these 
localities  the  parents  were  present  during  more  than  50  per  cent  of 
the  examinations. 

Methods  and  results  similar  to  those  outlined  are  features 
of  the  German  systems.  Unfortunately,  the  plan  has  never  been 
tried  on  any  extensive  scale  in  America  and  it  is  only  recently 
that  our  educational  authorities  have  begun  to  realize  that  true 
effectiveness  in  medical  inspection  is  in  a  large  measure  dependent 
upon  securing  the  active  co-operation  and  interest  of  the  parents. 

FOLLOW-UP  VISITS 

In  the  chapter  describing  the  work  of  the  school  nurse, 
reference  has  been  made  to  the  valuable  services  rendered  by  school 
nurses  in  following  up  cases  and  securing  action.*  Extended 
experience  in  many  localities  has  demonstrated  that  by  this 
method  the  percentage  of  pupils  receiving  remedial  attention  may 
be  greatly  increased  and  the  effectiveness  of  the  measures  taken 
greatly  enhanced. 

It  is  probably  safe  to  hazard  the  generalization  that  after 
systems  of  physical  examination  have  been  in  force  for  some  years 
the  percentage  of  children  receiving  remedial  attention  where  no 
follow-up  system  is  employed  is  apt  to  fall  to  about  15,  and  that 
where  there  is  a  follow-up  system  and  school  nurses  are  employed 
to  visit  the  homes  when  necessary,  this  percentage  can  be  held  at 
about  75. 

OFFICE  CONSULTATION 

In  many  of  the  more  efficient  American  systems  it  has  been 
found  desirable  for  the  school  physician  to  arrange  for  regular 

*  See  Chap.  V,  p.  62. 
76 


Team  work  between  physician  and  nurse  in  Toledo,  Ohio. 


MAKING   MEDICAL    INSPECTION    EFFECTIVE 


office  hours  during  which  he  can  be  consulted  by  the  parents  of 
the  children.  These  consultations  are  for  the  purpose  of  furnish- 
ing advice  and  not  for  the  purpose  of  giving  treatment.  They  are 
most  effective  in  securing  the  sympathetic  co-operation  of  the 
parents  with  the  work  and  aims  of  the  school  medical  department. 
The  forms  reproduced  below  and  on  page  78,  which  are  used  in 
the  public  schools  of  Oakland  and  Pasadena,  California,  are  good 
examples  of  cards  used  to  notify  parents  of  the  opportunity  for 
consulting  with  the  school  physician. 

NOTIFICATION  OF  DEFECTS  AND  OF  OPPORTUNITIES  FOR  CONSULTA- 
TION, OAKLAND,  CALIFORNIA 


School    :  OFFICE    OF 

I      DEPT.  OF  HEALTH  DEVELOPMENT  AND  SANITATION 
Qra(je  OAKLAND  SCHOOLS 

Pupil's  Name Date 

To  the  Guardian  or  Parent  of 

Parents'  Names 

Dear  Sir: 

••••;•• :          A  physical  examination  of  this  pupil  seems  to 

Address 

;  show  an  abnormal  condition  of  the 

Remarks  Kindly  take  the    child  to  your  family  physi- 

•  dan  or   specialist  for   advice  and  treatment  so  that 

i may  he  in  better  condition  to  continue 

i  studies. 

The  Director  will  be  in  his  office,  /fth  floor  of  the 
"  \  Central  Bank  Building,  from   1:30  to  4:30  p.  m., 
\  Mondays  and  Thursdays,  to  meet  parents  and  pupils 
Date i  for  consultation,  but  not  for  treatment. 

Very  respectfully, 
\  TAKE  THIS  TO  THE  PHYSICIAN   N.  K.  FOSTER,  Director. 


These  cards  serve  the  double  purpose  of  notifying  the  parent 
of  the  defects  discovered  and  telling  him  of  the  office  hours  of  the 
school  physician. 

In  Berkeley,  California,  a  card*  is  used  to  inform  the  parent 
of  the  physician's  office  hours  and  invite  him  to  visit  the  office. 

In  Oakland  another  formf  is  used  to  notify  the  parent  that 

*  See  p.  79.  t  See  p.  79. 

77 


MEDICAL   INSPECTION    OF    SCHOOLS 

NOTIFICATION   OF  DEFECTS  AND  OF  OPPORTUNITIES  FOR  CONSULTA- 
TION,   PASADENA,  CALIFORNIA 


NO. 

PASADENA  PUBLIC  SCHOOLS 
HEALTH  DEPARTMENT 

^School  Date 


On  careful  examination  we  find  that 
needs  attention  on  account  of 


The  Public  Schools  of  Pasadena,  through  their  health 
department,  are  looking  carefully  into  the  health  condition 
of  all  the  pupils  who  seem  to  need  such  attention.  It  is 
our  desire  that  parents  shall  co-operate  by  seeing  a  physi- 
cian, dentist,  or  other  specialist  as  the  case  may  require, 
without  delay.  The  child's  health  must  be  good  or  his  work 
will  suffer.  The  medical  examiner  gives  no  treatment,  his 
duty  is  to  advise  only.  He  will  be  glad  to  meet  parents 
for  further  consultation  and  advice,  at  the  office  of  the  City 
Superintendent  on  Mondays  and  Fridays  from  4  to  5  o'clock, 
provided  an  engagement  is  made  for  that  purpose. 

DR.  R.  C.  OLMSTED, 

Medical  Examiner 
(OVER) 

The  parent  will  kindly  indicate  what  can  be  done  in  this 
case  and  return  this  card,  signed,  at  the  earliest  possible 
time.  We  wish  to  check  up  the  return  messages  within  a 
week,  if  possible. 

In  cases  where  parents  cannot  pay  the  usual  charges  for 
medical  or  dental  treatment,  special  arrangements  will  be 
made  on  consultation  with  the  medical  examiner. 

(INDICATE  HERE  WHAT  CAN  BE  DONE) 

Signed 


PARENT  OR  GUARDIAN 


MAKING    MEDICAL    INSPECTION    EFFECTIVE 

the  school  nurse  has  called  at  the  home  during  the  absence  of  the 
parent.  This  card  includes  an  invitation  to  call  at  the  office  for 
consultation  with  the  medical  director. 

NOTIFICATION  TO   PARENTS   OF    SCHOOL    PHYSICIAN'S  OFFICE    HOURS 


Health  and  Development  Department 
Berkeley  Schools 


I 


CARD  TO  PARENTS 
F  you  will  bring 


to  the  office  of  the  School  Physician,  in  the  High  School 
Building,  any  Tuesday,  Thursday  or  Friday  afternoon  be- 
tween 2:30  and  4  o'clock,  he  will  be  very  glad  to  give  you 
additional  information,  and  to  advise  you  about  obtaining 
medical  or  dental  attention. 

MEDICAL  DIRECTOR  OF  SCHOOLS 


NOTIFICATION  OF  NURSE  S  CALL  AND  OF  SCHOOL  PHYSICIAN  S  OFFICE 
HOURS,  OAKLAND,  CALIFORNIA 


DEPARTMENT  OF  HEALTH  DEVELOPMENT  AND  SANITATION 
OAKLAND  PUBLIC  SCHOOLS 

1358  Broadway, 191 .  . 

The  School  Nurse  failed  to  find  you  at  home  when  she 

called  to  consult  with  you  regarding  the  condition  of 

who  was  examined and  reported  for 

We  desire  to  work  with  the  parents  to 

better  the  health  and  strength  of  the  children,  and  request 
that  you  either  call  in  person  or  report  to  this  office  if  any 
attention  has  been  given  the  reported  defect 

Very  respectfully, 

N.  K.  FOSTER,  Director 
Office  Days 
Monday  and  Thursday,  1:30  to  4:30  p.  m. 

.  .Nurse. 


79 


MEDICAL    INSPECTION    OF    SCHOOLS 

COMMUNITY  EDUCATION  THROUGH  PRINTED  BULLETINS 

Nearly  all  well  developed  systems  have  some  form  of  printed 
bulletin  for  instructing  parents  as  to  the  methods  and  aims  of 
medical  inspection,  the  importance  of  conditions  found,  and 
steps  necessary  to  remedy  them.  Examples  of  such  instructions 
with  respect  to  the  care  of  pediculosis  are  to  be  found  in  the 
chapter  on  contagious  disease,  while  similar  instructions  in  regard 
to  certain  phases  of  dental  work  will  appear  in  the  chapter  on 
dental  inspection. 

Quite  the  best  series  of  such  bulletins  is  that  prepared  by 
Dr.  Ernest  Bryant  Hoag  of  California  and  widely  used  in  the 
cities  of  that  state.  These  bulletins  are  in  the  form  of  two-page 
leaflets  measuring  3>£x  5^  inches,  which  are  designed  for  distribu- 
tion among  parents  and  children.  They  give  in  condensed  and 
effective  form  authoritative  information  concerning  the  impor- 
tance of  the  more  common  physical  defects.  Several  of  them 
are  reproduced  in  Dr.  Hoag's  excellent  little  book  The  Health  In- 
dex of  Children.  This  method  of  public  education  is  so  effective 
and  Dr.  Hoag's  Health  Pamphlets  are  so  admirably  designed  to 
serve  their  purpose  that  two  of  them  are  reproduced  herewith. 
Another  of  the  same  series  dealing  with  the  teeth  is  reproduced 
in  the  chapter  on  dental  inspection. 

HEALTH  PAMPHLET  NO.  i 

by 
Dr.  Ernest  Bryant  Hoag 

THE    RESULTS  OF  NOSE,  THROAT  AND   EAR   TROUBLES   IN 
CHILDREN 

An  examination  of  school  children  shows  that  many  of 
them  suffer  from  nose,  throat  and  ear  troubles.  Probably 
at  least  25%  of  our  children  in  the  schools  of  the  United  States 
have  such  defects.  Why  this  is  so  we  do  not  know. 

Parents  are  very  likely  to  be  unfamiliar  with  these  con- 
ditions. Often  they  do  not  know  when  their  own  children 
are  afflicted  in  this  way.  It  is  the  business  of  the  School  Med- 
ical Examiner,  employed  by  the  Boards  of  Education  or 
Boards  of  Health,  to  discover  children  who  need  medical  at- 
tention. 

80 


MAKING   MEDICAL    INSPECTION    EFFECTIVE 

No  child  can  do  his  best  work  in  school  if  he  is  suffering 
from  some  nose,  throat  or  ear  trouble.  The  commonest  con- 
ditions found  in  such  children  are  enlarged  diseased  tonsils, 
adenoids  and  deafness. 

The  tonsils  are  glands  in  the  throat,  one  on  each  side  of 
the  root  of  the  tongue.  When  they  are  in  a  healthy  con- 
dition they  are  barely  visible.  They  often  become  much  in- 
flamed and  sometimes  there  is  pus  present  in  them.  They 
may  obstruct  breathing. 

Any  child  with  diseased  tonsils  is  likely  to  be  sickly. 

Any  child  with  diseased  tonsils  is  likely  to  have  many 
attacks  of  sore  throat,  or  tonsilitis. 

Any  child  with  diseased  tonsils  is  very  susceptible  to 
contagious  diseases. 

Any  child  with  diseased  tonsils  Has  A  TENDENCY 
TOWARD  CONSUMPTION. 

No  child  can  be  well  or  do  his  best  work  in  school  with 
diseased  tonsils. 

Diseased  tonsils  should  usually  be  removed  and  should  al- 
ways be  treated.  The  operation  is  not  dangerous.  It  al- 
ways improves  the  child's  health. 

Adenoids  are  soft  spongy  growths  behind  the  soft  pal- 
ate, between  the  nose  and  throat.  A  child  with  adenoids 
usually  breathes  with  his  mouth  open.  He  cannot  breathe 
well  through  his  nose.  Mouth  breathing  is  not  a  habit.  If  a 
child  breathes  with  his  mouth  open  it  is  because  there  is  some 
obstruction  in  the  nose. 

Adenoids  cause  a  child  to  sleep  with  his  mouth  open. 

Adenoids  often  cause  a  child  to  snore. 

Adenoids  nearly  always  make  the  teeth  come  in  crooked. 

CROOKED  AND  PROMINENT  TEETH  ARE 
NEARLY  ALWAYS  CAUSED  BY  ADENOIDS. 

Adenoids  make  a  child  take  cold  easily. 

Adenoids  often  give  a  child  a  stupid  appearance. 

Adenoids  often  RESULT  IN  ACTUAL  STUPIDITY, 
because  the  child  cannot  get  enough  air. 

Adenoids  often  cause  ear  ache  and  deafness  with  some- 
times a  running  ear.  Catarrh,  deafness,  ear  ache  and  dis- 
charge from  the  ear  are  more  often  due  to  some  obstruction 
in  the  nose  or  throat  than  to  anything  else. 

Adenoids  usually  result  in  delicate  health. 

6  8l 


MEDICAL    INSPECTION    OF    SCHOOLS 

Adenoids  MUST  BE  REMOVED  if  you  expect  a  child  to 
be  healthy  or  mentally  bright. 

It  is  an  injustice  to  children  to  neglect  caring  for  them 
when  adenoids  or  diseased  tonsils  are  present.  It  is  very 
poor  economy  on  the  part  of  the  parent  to  neglect  the  treat- 
ment of  children  so  affected.  Any  child  will  grow  up  health- 
ier, happier,  and  more  useful  if  these  conditions  are  taken 
care  of. 

HEALTH  PAMPHLET  NO.  2 

by 

Dr.  Ernest  Bryant  Hoag 
THE  RESULTS  OF  DEFECTIVE  EYE-SIGHT 

Defects  of  eye-sight  in  school  children  are  very  common. 
Probably  at  least  20%  of  the  children  of  our  American  schools 
suffer  from  such  defects. 

These  defects  not  only  cause  a  great  deal  of  trouble  in 
the  eyes  themselves,  but  often  produce  many  other  serious 
results,  which  do  not  at  first  seem  to  be  connected  with  the 
eyes. 

The  proper  treatment  of  children's  eyes  will  nearly  al- 
ways bring  good  results.  In  this  way  they  will  often  be  saved 
from  life-long  suffering. 

A  child's  education  will  not  be  worth  much  to  him  if  he 
does  not  have  good  eye-sight.  The  ability  to  earn  a  living 
depends  very  largely  upon  good  eye-sight.  It  is  very  poor 
economy  to  neglect  to  care  for  defects  in  the  eyes  of  children, 
for  sooner  of  later  such  children  may  become  burdens  upon 
some  one. 

The  common  defects  in  the  eyes  of  children  are  as  follows : 

1.  NEAR  SIGHT 

This  condition  is  very  serious.  It  not  only  limits  the 
child's  range  of  vision  and  prevents  his  taking  part  in  health 
giving  sports  and  recreation,  but  it  produces  changes  in  the 
eyes  which  often  result  in  practical  blindness. 

2.  FAR  SIGHT 

This  condition  is  more  common  than  near  sight.  It 
results  in  eye  strain  and  often  causes  squinting,  red  eyes, 
headache,  nervousness,  backwardness  in  studies,  and  some- 
times digestive  disorders  and  poor  health  generally. 

82 


* 


MAKING   MEDICAL   INSPECTION    EFFECTIVE 

3.  ASTIGMATISM 

This  is  the  most  common  of  all  eye  defects.  It  results 
in  blurred  vision,  headache,  nervousness,  and  other  kinds  of 
discomfort.  It  may  be  associated  with  either  near  sight  or 
far  sight. 

4.  CROSS  EYES  OR  SQUINT 

This  is  often  the  result  of  FAR  Sight.  It  is  absolutely 
necessary  to  have  this  defect  corrected.  In  children  this  can 
usually  be  done  with  glasses  alone.  If  the  trouble  is  not  cured 
the  vision  of  the  crossed  eye  will  become  poorer  and  poorer 
UNTIL  AT  LAST  THIS  EYE  BECOMES  BLIND. 

5.  INFLAMED  OR  RED  EYES 

This  condition  is  often  caused  by  a  defect  in  vision, 
but  frequently  it  is  due  to  INFECTION.  That  is,  some- 
thing has  gotten  into  the  eyes  and  carried  PUS-PRODUC- 
ING GERMS  WITH  IT. 

Serious  eye  disorders  are  sometimes  "caught"  from 
dirty  towels,  public  bathing  pools,  dirty  hands,  or  dust. 

Each  child  and  grown  person  should  use  only  his  own 
towel.  Red  sore  eyes  ought  never  to  be  neglected.  Remem- 
ber that  many  cases  of  sore  eyes  are  contagious  and  that  all 
such  cases  need  the  attention  of  a  doctor. 

Peculiar  postures,  holding  the  head  on  one  side,  squint- 
ing, miscalling  words  and  headache  should  always  raise  the 
suspicion  of  possible  eye  trouble. 

LEGAL  COMPULSION 

Two  of  the  states  which  have  framed  regulations  or  enacted 
laws  on  medical  inspection  have  provided  for  compulsory  action 
against  parents  who  fail  to  act  upon  notification  of  disease  or 
defect  in  their  children. 

Colorado,  in  the  law  passed  in  1 909,  provided  that 

"  If  the  parents  or  guardian  of  such  child  [i.e.,  one  found  defective 
concerning  whom  notification  of  need  of  treatment  has  been  sent]  shall 
fail,  neglect,  or  refuse  to  have  such  examination  made  and  treatment  be- 
gun within  a  reasonable  time  after  such  notice  has  been  given,  the  said 
principal  or  superintendent  shall  notify  the  State  Bureau  of  Child  and  An- 
imal Protection  of  the  facts  .  .  .  ." 

83 


MEDICAL   INSPECTION    OF    SCHOOLS 

The  procedure  regarding  such  cases  is  further  elaborated  in 
a  circular  letter  of  instructions  to  teachers  and  principals: 

"The  Physician's  Report  is  to  be  returned  to  the  Teacher.  If 
within  a  reasonable  time  the  Physician's  Report  is  not  received  by  the 
Teacher  or  proves  to  be  unsatisfactory;  or  where  in  lieu  thereof  the  par- 
ent or  guardian  sends  a  written  statement  that  he  has  not  the  necessary 
funds  wherewith  to  pay  the  expenses  of  such  examination  and  treatment 
the  Teacher  will  send  a  Failure  Notice  (with  such  written  statement  if 
any)  to  the  Principal  or  County  Superintendent,  recording  same  on  the 
pupil's  Teacher's  Record  Card. 

"The  Principal  or  County  Superintendent  will  record  the  Failure 
Notice  on  Pupil's  Record  Card  and  forward  the  Notice  to  the  State  Bu- 
reau of  Child  and  Animal  Protection,  State  House,  Denver. 

"If  a  written  statement  of  inability  to  pay  accompanies  a  Failure 
Notice,  the  Principal  or  County  Superintendent  will  at  once  'cause  such 
examination  and  treatment  to  be  made  by  the  County  Physician  of  the 
District  wherein  said  child  resides';  who  if  unable  to  treat  such  child 
shall  forthwith  report  such  fact  to  the  County  Commissioners  with  his 
recommendation.  If  satisfactory  results  are  not  had  within  a  reasonable 
time,  the  Failure  Notice,  written  statement  of  inability  to  pay,  statement 
of  reference  to  County  Physician,  etc.,  with  other  information  germaine 
to  the  case  is  to  be  forwarded  by  the  Principal  or  County  Superintendent 
to  the  State  Bureau  of  Child  and  Animal  Protection. 

"What  constitutes  a  'reasonable  time'  will  be  left  to  the  judg- 
ment of  the  Teacher,  under  the  advice  and  direction  of  the  Principal  or 
County  Superintendent.  If,  after  taking  all  the  circumstances  into  con- 
sideration, doubt  exists,  refer  the  matter  to  the  Bureau  of  Child  and 
Animal  Protection,  with  full  particulars. 

"Whatever  unpleasant  or  difficult  duty  may  arise  in  the  enforce- 
ment of  the  law  for  the  examination  and  care  of  School  Children,  is  laid 
by  the  law,  not  upon  the  Teacher,  the  Principal,  the  County  Superin- 
tendent or  the  State  Superintendent  of  Public  Instruction,  but  upon  the 
State  Bureau  of  Child  and  Animal  Protection. 

"Whenever  the  State  Bureau  of  C.  and  A.  P.  receives  a  Failure 
Notice  it  will  at  once  send  its  own  notice  to  the  Parent  or  Guardian  re- 
questing compliance  with  the  law,  and  will,  at  the  same  time  notify  the 
Teacher  of  that  action. 

"In  most  cases  a  notice  from  the  Bureau  will  be  sufficient  to  in- 
duce prompt  obedience  to  the  law.  If,  however,  they  still  'fail,  refuse  or 
neglect,'  the  Teacher  will  send  a  second  Failure  Notice,  marked  'No.  2,' 

84 


MAKING   MEDICAL    INSPECTION    EFFECTIVE 

to  the  Principal  or  County  Superintendent,  who  will  forward  it  to  the 
State  Bureau  of  C.  and  A.  P.  at  the  State  House,  Denver. 

"When  the  Bureau  of  C.  &  A.  P.  receives  a  Failure  Notice  accom- 
panied by  a  written  statement  of  inability  to  pay,  etc.,  it  will  investigate 
and  assist. 

"When  the  Bureau  receives  a  second  Failure  Notice  it  will  send 
an  officer  who  will  first  consult  with  the  Teacher,  if  possible  with  the 
Principal  or  County  Superintendent,  and  acting  under  the  direction  of 
the  Bureau  will  take  charge  of  the  case. " 

Regarding  action  under  this  law,  the  report  of  the  Colorado 
State  Superintendent  of  Public  Instruction  for  1909-10  has  this 
to  say : 

"Out  of  the  41,546  cases  of  defectiveness  reported  to  the  State 
Superintendent  of  Public  Instruction  as  having  been  discovered,  and  pre- 
sumably reported  to  the  parents  of  the  children,  221  cases  were  reported 
by  teachers  to  the  State  Bureau  of  Child  and  Animal  Protection  for 
failure  of  parents  to  have  the  medical  examination  indicated  by  the 
teachers'  examination  made.  Whether  this  was  the  total  number  of 
cases  which  should  have  been  reported  we  have  no  means  of  knowing. 
In  the  absence  of  further  information  it  may  be  assumed  that  it  does  not 
depart  far  from  the  total  which  should  have  been  referred. 

"With  one  exception  the  parents  in  all  these  cases  were  induced 
by  letter  or  by  the  visit  of  our  officer  to  do  whatever  the  children's  con- 
dition required.  In  the  one  case  where  it  was  necessary  to  bring  the 
parents  into  court  the  child's  throat  was  nearly  closed  by  enlarged  tonsils 
and  his  health  seriously  affected.  At  the  trial  the  father  was  sentenced 
to  thirty  days'  imprisonment." 

The  New  Jersey  law,  passed  also  in  1909,  provides  as  follows: 

"If  the  cause  for  exclusion  is  such  that  it  can  be  remedied,  and 
the  parent,  guardian  or  other  person  having  control  of  the  child  excluded 
as  aforesaid  shall  fail  or  neglect  within  a  reasonable  time  to  have  the 
cause  for  such  exclusion  removed,  such  parent,  guardian  or  other  person 
shall  be  proceeded  against,  and,  upon  conviction,  be  punishable  as  a  dis- 
orderly person. " 

No  record  of  action  under  this  provision  of  the  law  has  been 
found.  Neither  the  report  of  the  New  Jersey  Superintendent 
of  Public  Instruction  for  1909-10  nor  any  of  the  21  reports  from 
county  superintendents,  or  the  30  reports  from  city  superintend- 

85 


MEDICAL    INSPECTION    OF    SCHOOLS 

ents  contained  in  the  same  volume,  mentions  this  clause  of  the 
law,  though  most  of  them  contain  statements  regarding  medical 
inspection.  One  county  superintendent  writes:  "The  weakest 
place  in  the  system  seems  to  be  lack  of  efficient  remedy  when 
defects  are  discovered  of  a  nature  not  infectious  or  contagious/' 

In  England  many  fines  have  been  imposed  (some  under 
attendance  by-laws,  others  under  a  clause  of  the  children's  act) 
upon  parents  who  failed  to  cleanse  or  keep  clean  the  bodies  and 
heads  of  their  children.  Parents  who  neglected  and  ill-treated 
their  children  have  also  been  imprisoned  or  fined,  another  clause 
of  the  children's  act  being  invoked  in  their  cases.  In  this  latter 
group  of  cases  are  included  those  of  children  suffering  from  defec- 
tive eyesight,  enlarged  tonsils  and  adenoids,  decayed  teeth,  and 
ulcerated  mouths.  Many  such  children  were  treated  after  the 
cases  had  been  brought  into  court,  with  the  result  that  proceedings 
against  the  parents  were  stopped. 


SCHOOL  AND  HOSPITAL  CLINICS 

Wherever  systems  of  medical  inspection  become  highly 
developed  and  the  authorities  attempt  to  make  the  work  effective, 
they  are  confronted  with  the  problem  of  what  to  do  to  secure 
adequate  treatment  for  children  whose  parents  either  cannot  pay 
for  it  at  all  or  can  pay  only  a  small  fee.  The  services  of  the 
school  nurse  are  effective  in  securing  action  on  the  part  of  many 
parents  who  would  otherwise  take  no  action  whatever,  but  there 
always  remain  a  considerable  number  of  parents  who  are  willing 
that  their  children  should  receive  treatment  but  who  are  unable 
to  meet  any  large  expense  involved. 

Thus  the  school  nurse  alone  cannot  meet  the  situation  and 
some  agency  must  be  provided  to  cope  with  the  problem.  In 
most  cases  this  agency  is  a  hospital,  more  rarely  a  clinic  established 
within  the  school  itself.  In  either  case  it  is  generally  true  at  the 
present  time  in  American  cities  that  facilities  are  inadequate  to 
meet  the  need. 

In  Great  Britain  the  policy  of  the  board  of  education  since 
the  adoption  of  the  medical  inspection  law  in  1907  has  been  to 
urge  local  school  authorities  to  secure  the  utmost  possible  degree 

86 


MAKING   MEDICAL   INSPECTION    EFFECTIVE 

of  co-operation  from  existing  hospitals  and  clinics.  Where  such 
institutions  have  been  of  high  character,  but  limited  in  capacity 
by  their  small  endowments,  special  government  subsidies  have  in 
some  instances  been  approved  in  order  to  permit  the  extension 
of  their  work  to  care  for  cases  referred  from  the  public  schools. 

Nevertheless,  these  measures  have  frequently  been  found 
inadequate,  and  prior  to  1911  school  clinics  for  the  treatment  of 
skin  and  scalp  diseases  and  in  some  instances  for  the  care  of 
defective  teeth,  eyes,  ears,  and  throats,  had  been  established  in 
30  cities. 

Almost  the  only  writer  on  medical  inspection  in  America 
who  has  faced  the  problem  of  inadequate  treatment  squarely  is 
Dr.  George  J.  Holmes,  supervisor  of  medical  inspection  in  Newark, 
New  Jersey,  whose  views  are  outlined  in  the  following  quotations 
from  his  article  published  in  the  Journal  of  the  Medical  Society 
of  New  Jersey,  1911. 

"  I  have  suggested  that  free  public  school  clinics  be  established  to 
care  for  all  diseases  and  defects  common  to  school  pupils.  No  pupil  to 
be  admitted  unless  attending  a  public  school,  presenting  a  printed  slip 
showing  that  he  or  she  has  been  referred  for  treatment  by  a  medical  in- 
spector, and  that  his  or  her  home  has  been  visited  by  a  school  nurse,  find- 
ing such  poverty  that  free  treatment  is  necessary  and  right. 

"Were  such  a  clinic  established  by  the  Board  of  Education  and 
conducted  by  the  supervisor  of  medical  inspection  and  his  assistants, 
both  physicians  and  nurses,  it  would  no  longer  be  necessary  for  a  pupil 
to  leave  school  during  session  for  treatment  or  examination.  Pauperism 
would  not  be  fostered.  Such  a  clinic  should  be  held  from  three  to  six 
p.  m.  daily,  except  Sundays. 

"Other  benefits  resulting  from  school  clinics  would  be  the  creating 
of  greater  interest  among  the  physicians  and  nurses  of  the  department, 
in  their  being  able  to  follow  the  cases  and  see  the  results.  Greater  op- 
portunity would  be  afforded  both  physicians  and  nurses  to  meet  parents 
of  the  children  afflicted,  and  opportunity  for  preaching  and  impressing 
the  common  facts  relating  to  personal  and  home  hygiene  on  the  parents. 
Greater  results  would  be  obtained  and  better  opportunity  would  be  given 
the  supervisor  to  observe  the  work  of  each  member  of  the  department." 

It  is  probable  that  few  of  the  educational  authorities  in 
this  country  would  be  prepared  to  accept  so  radical  a  proposition 

8? 


MEDICAL    INSPECTION    OF    SCHOOLS 

as  that  of  Dr.  Holmes.  So  far  as  is  known,  the  only  strictly 
school  clinics  conducted  in  the  United  States  are  the  dental 
clinics  in  Rochester,  Cincinnati,  Muskegon,  Philadelphia,  and 
Elmira,  and  the  eye  clinic  in  Cleveland.  The  time  is  undoubt- 
edly at  hand,  however,  when  some  solution  to  the  pressing  prob- 
lem created  by  needy  children  left  untreated  must  be  sought  out 
and  applied.  Frank  facing  of  the  problem  is  needed  if  medical 
inspection  is  to  fulfill  the  hopes  of  its  friends. 

SUMMARY. — Invitations  to  parents  to  be  present  at  examina- 
tions of  children,  follow-up  visits  by  nurses,  arrangements  for 
children  to  attend  hospitals  and  clinics,  the  establishment  of 
office  hours  when  medical  supervisors  may  be  consulted  by  parents, 
and  the  education  of  the  community  through  printed  bulletins 
explaining  the  nature  and  importance  of  defects,  are  five  measures 
of  great  value  in  rendering  medical  inspection  effective. 

Mere  notifications  of  defects,  unsupplemented  by  such 
measures  as  the  above,  can  never  be  expected  to  secure  more  than 
a  small  proportion  of  the  treatments  needed.  The  possibilities 
of  increasing  the  effectiveness  of  medical  inspection  by  legal 
measures  to  compel  neglectful  parents  to  take  action  have  not 
yet  been  thoroughly  tested  in  this  country,  but  the  working  of 
Colorado's  experiment  along  this  line  is  worth  study. 

The  presence  throughout  the  schools  of  the  country  of  large 
numbers  of  children  whose  parents  cannot  afford  to  pay  current 
rates  for  treatment  creates  a  problem  which  is  pressing  for  solution. 
The  suggestion  that  dental  and  medical  school  clinics  be  estab- 
lished to  deal  with  this  class  of  cases  will  increasingly  demand  the 
attention  of  school  authorities  who  are  dissatisfied  with  the 
inadequate  returns  secured  by  present  systems  of  medical  inspec- 
tion. 


CHAPTER  VII 
RESULTS 

DEFINITE  information  as  to  the  actual  results  achieved  by 
medical  inspection  for  the  detection  and  correction  of 
physical  defects  is  exceedingly  meager.     Superintendents 
and  health  officers  frequently  state  in  their  annual  reports  that 
the  response  of  parents  to  notifications  is  unsatisfactory,  and  urge 
the  adoption  of  more  effective  follow-up  methods.     Where  nurses 
have  recently  been  installed,  satisfaction  is  generally  expressed 
and  the  statement  made  that  a  marked  increase  of  co-operative 
action  has  resulted.    Definite  statistical  evidence  is,  however,  rarely 
offered  with  regard  to  any  phase  of  the  problem. 

The  success  of  a  system  of  medical  inspection  of  schools  is 
to  be  measured  by  the  results  achieved.  The  mere  piling  up  of 
statistical  data  as  to  defects  would  be  valueless  unless  action  of 
some  sort  followed.  In  printed  reports,  the  meaning  attached  to 
the  word  "results"  is  the  crux  of  the  whole  matter.  In  most 
cases  where  any  mention  is  made  of  results  secured  it  takes  the 
form  of  "treatments  reported/'  "attention  given/'  or  "physician 
consulted/'  Occasionally  some  detail  is  entered  into,  as  the  num- 
ber of  pairs  of  glasses  obtained  or  the  number  of  operations  per- 
formed. Very  rarely  a  notation  as  to  improvements  following 
treatment  is  made. 

The  type  of  report  on  results  which  a  school  physician 
makes  is  naturally  determined  by  his  conception  of  the  function 
of  his  office.  On  the  side  of  results,  four  possible  functions  may  be 
formulated : 

1.  To  bring  parents  to  the  point  of  taking  their  children  to  a 
physician  or  dentist,  clinic  or  hospital. 

2.  To  ascertain  whether  the  consultation  is  a  genuine  one  and 
whether  appropriate  treatment  has  been  instituted. 

3.  To  ascertain,  where  no  treatment  or  inadequate  treatment  only 

89 


MEDICAL    INSPECTION    OF    SCHOOLS 

has  been  given,  what  is  the  reason  for  such  failure  (i.  e.  parental  igno- 
rance, indifference,  hostility  or  poverty,  lack  of  clinical  resources,  etc.). 

4.  To  ascertain  the  ultimate  results  of  treatment  upon  the  child's 
physical  health  and  mental  development. 

The  first  function  is  inevitably  the  one  first  recognized,  as 
it  is  undoubtedly  the  most  important.  The  second  function  is 
almost  forced  upon  the  inspector  where  later  contact  with  a  child 
reported  "under  treatment"  leads  to  the  discovery  that  no 
effective  measures  to  remedy  bad  conditions  have  been  taken. 
It  is  especially  important  in  large  cities  where  unprincipled 
practitioners  find  it  easy  to  connive  with  parents  in  a  pretense 
of  consultation.  Yet  assumption  of  the  duties  and  responsi- 
bilities it  implies  is  rare  in  American  cities.  The  third  function 
follows  naturally  upon  the  second  and  would  call  for  but  little 
additional  work. 

The  fourth  function  is  as  yet  recognized  by  scarcely  any 
American  community.  It  can  be  developed  to  its  fullest  possible 
limits  only  where  there  is  active  and  enthusiastic  co-operation 
of  teachers  and  principals  with  medical  officers.  Such  following 
up  of  children  as  it  requires  is  far  more  difficult  in  large  cities  than 
in  small  towns,  since  transfers  from  school  to  school  mean  re- 
examinations  by  different  inspectors,  in  which  case  comparison 
of  "before"  and  "after"  conditions  becomes  unreliable.  Records 
of  re-inspections  by  physicians  when  sufficient  time  has  elapsed 
after  treatment  so  that  definite  results  are  discoverable,  and  records 
by  teachers  of  their  observations  during  extended  periods  are, 
however,  essential  features  of  any  scheme  for  testing  the  value 
to  the  child  and  to  the  community  of  medical  inspection. 

The  report  of  a  school  physician  who  based  his  work  on 
the  assumption  that  all  the  above  functions  belonged  to  his 
office  would  be  likely  to  contain  several  features  not  now  generally 
found  in  such  reports.  Among  them  would  probably  be: 

A  statement  of  the  number  of  children  enrolled,  the  number  ex- 
amined, the  number  having  specified  defects  and  combinations  of  defects, 
and  the  number  reported  as  having  consulted  a  private  physician  or 
dentist,  or  as  having  been  taken  to  a  clinic  or  hospital  for  treatment. 

A  statement  of  the  number  of  these  children  found  on  investiga- 
tion, after  a  stated  period  following  the  reported  consultation  has  elapsed, 

90 


RESULTS 

to  have  received  adequate  treatment,  the  kind  of  treatment  being  speci- 
fied. 

A  statement  of  sources  of  treatment;  that  is,  private  physicians 
or  dentists,  specialists,  clinics,  hospitals,  etc.,  with  number  of  children 
treated  by  each. 

A  statement  of  the  number  of  children  who  failed  to  receive  ef- 
fective treatment,  classified  to  show  causes  of  failure;  that  is,  parental 
neglect  or  opposition,  poverty,  lack  of  adequate  or  accessible  clinics, 
lack  of  intelligent  co-operation  by  clinics  and  family  physicians,  etc. 

A  statement  of  ultimate  results  on  health  and  school  standing  pro- 
duced by  specified  kinds  of  treatment  in  children  suffering  from  each  sort 
of  defect. 

Such  a  report  would  furnish  a  basis  for  the  formulation  of 
policies  now  generally  lacking.  If,  for  example,  it  revealed  a 
large  amount  of  parental  neglect  of  serious  conditions  when 
adequate  means  of  securing  treatment  for  such  conditions  existed 
in  the  community,  the  need  of  a  new  type  of  educational  activity 
directed  toward  the  older  generation  would  be  made  evident.  If 
on  the  other  hand  there  were  revealed  many  cases  where  lack  of 
facilities  for  medical,  surgical,  or  dental  treatment  was  the  cause 
of  unsatisfactory  results,  the  problem  of  securing  adequate  facili- 
ties for  treatment  would  be  placed  squarely  before  the  educational 
and  health  authorities  with  its  alternative  of  continued  waste 
of  public  funds  in  ineffective  inspection. 

RECORDS  OF  DEFECTS  TREATED  IN  NEW  YORK  CITY 

New  York  occupies  the  first  place  in  the  discussion  of  this 
subject,  both  on  account  of  the  size  of  its  problem  and  because  the 
history  of  its  endeavor  to  cope  with  that  problem  is  an  unusually 
long  and  instructive  one.  Treatments,  as  reported  by  the  Division 
of  Child  Hygiene  of  the  Department  of  Health  for  the  year  191 1, 
include  all  cases  where  report  of  attention  received  was  made  by 
physicians.  Instructions  in  mouth  hygiene  by  nurses,  said  to  have 
been  given  in  all  cases  where  defective  teeth  were  discovered,  are 
not  included.  The  figures  undoubtedly  include  many  cases  where 
treatment  never  went  beyond  the  initial  visit  to  a  physician. 
Moreover,  according  to  the  director  of  the  Division  of  Child 
Hygiene  of  the  Department  of  Health,  they  include  cases  where 

91 


MEDICAL    INSPECTION    OF    SCHOOLS 


physicians,  without  examination  and  for  a  fee  of  25  cents,  have 
furnished  diagnoses  agreeing  with  those  of  the  medical  inspectors 
on  the  slips  brought  them  by  the  children.  There  is,  however,  no 
reason  to  suppose  that  the  figures  given  are  any  less  reliable  than 
those  reported  from  other  cities.  The  data  showing  in  detail  the 
number  and  per  cent  of  defects  treated  are  presented  in  Table  20. 

TABLE  2O. — PHYSICAL  DEFECTS  REPORTED  BY  MEDICAL  INSPECTORS, 

AND  NUMBER    AND    PER    CENT    OF    THESE    DEFECTS    TREATED. 

NEW  YORK  CITY,   1 9!  I 


Defect 

Cases 
reported 

Cases 
treated 

Per  cent 
treated 

Vision     .... 

24,5M 

16,633 

68 

Hearing  .... 

1,491 

847 

57 

Nasal  breathing    . 

27,319 

22,839 

84 

Hypertrophied  tonsils 

34,639 

22,647 

65 

Tuberculous  lymph  nodes 

418 

295 

Cardiac  disease 

i,  66  1 

1,286 

77 

Pulmonary  disease 

78 

Chorea    .... 

86  1 

483 

56 

Orthopedic     . 

1,190 

522 

44 

Malnutrition 

5.845 

3,632 

62 

Teeth      .... 

135.843 

18,164 

13 

Palate     .... 

85 

40 

47 

Total  .... 

234,349 

87,765 

37 

In  the  case  of  four  of  the  defects,  further  details  are  given 
as  to  the  character  of  the  remedial  treatment.  These  details 
are  as  follows: 


Defective  vision: 

Treated  by  supplying  glasses    . 
Receiving  medical  treatment    . 

Defective  nasal  breathing: 

Receiving  operative  treatment 
Receiving  medical  treatment 

Hypertrop  b  ied  tons  Us : 

Receiving  operative  treatment 
Receiving  medical  treatment 

Defective  teeth: 

Treated  by  extraction 
Treated  by  filling 


11,304 
5.329 

11,284 
1I>555 

9,808 
12,839 


7,373 
10,791 


It  is  interesting  to  note  that  the  highest  percentage  of 
treatments  was  that  reported  in  cases  of  defective  nasal  breath- 

92 


RESULTS 

ing  where  over  80  per  cent  were  treated,  more  than  40  per  cent  by 
operation.  In  nearly  all  other  classes  of  defects,  upwards  of 
50  per  cent  of  cases  were  reported  treated,  but  the  very  low  per- 
centage of  cases  of  defective  teeth  which  received  attention  is 
in  striking  contrast,  and  evidently  accounts  for  the  fact  that  but 
37  per  cent  of  all  the  defects  needing  attention  received  it. 

Lack  of  appreciation  of  the  need  of  dental  care,  and  lack  of 
clinics  where  teeth  can  be  put  in  order  at  a  moderate  cost,  are 
doubtless  alike  reflected  in  the  low  percentages  of  extractions  and 
fillings. 

REPORTS  FROM  OTHER  CITIES 

In  the  report  of  medical  inspection  in  the  schools  of  Newark, 
New  Jersey,  occurs  the  following  statement  showing  the  definite 
action  taken  on  defects  of  vision,  hypertrophied  tonsils,  adenoids, 
and  defective  teeth;  that  is,  provision  of  glasses,  operations  for 
tonsils  and  adenoids,  and  dental  treatment. 

TABLE    21. — FOUR    CLASSES  OF    PHYSICAL   DEFECTS   REPORTED   AND 
NUMBER  AND   PER  CENT  OF  THESE  DEFECTS  TREATED. 
NEWARK,  N.  J., 


Defect 

Cases 
reported 

Cases 
treated 

Per  cent 
treated 

Vision     
Tonsils    
Adenoids        
Teeth      

3,003 
4,588 
1,866 
7.124 

989 
416 
238 

772 

33 
9 
13 
ii 

Total  

16,581 

2,415 

15 

As  the  table  shows,  the  percentage  of  defects  receiving  the 
specified  remedial  treatment  was  15.  The  corresponding  figures 
cited  for  New  York  City  give  a  percentage  of  nearly  23.  In  the 
New  York  report  the  term  "defective  nasal  breathing"  is  con- 
sidered equivalent  to  the  term  "adenoids"  in  the  Newark  one. 
In  general,  the  figures  make  it  appear  that  Newark  is  somewhat 
behind  its  larger  neighbor  in  the  treatment  of  eyes,  ears,  and 
throats,  and  about  on  a  par  in  the  treatment  of  defective  teeth. 

Harrisburg,  Pennsylvania,  gives  the  following  statement  of 
reported  treatments  for  the  school  year  1909-10: 

93 


MEDICAL   INSPECTION    OF    SCHOOLS 


TABLE    22. — PHYSICAL    DEFECTS    RECOMMENDED    FOR    TREATMENT 
AND    NUMBER    AND    PER    CENT    OF   THESE    DEFECTS    TREATED. 
HARRISBURG,     PA., 


Defect 

Cases 

recommended 
for  treatment 

Cases  reported 
treated 

Per  cent  of 
recommended 
cases  reported 
treated 

Malnutrition      .... 

72 

24 

33 

Enlarged  cervical  glands 

17 

4 

24 

Chorea        

8 

4 

50 

Cardiac  disease 

8 

3 

38 

Pulmonary  disease    . 

5 

4 

80 

Skin  disease       .... 

61 

30 

49 

Defective  vision 

677 

268 

40 

Defective  hearing 

'43 

51 

36 

Defective  nasal  breathing 

204 

83 

4i 

Defective  teeth 

187 

48 

26 

Deformed  palate 

8 

2 

25 

Hypertrophied  tonsils 

805 

249 

3« 

Adenoids    ..... 

432 

>53 

35 

Total       

2,627 

923 

35 

The  numbers  here  are  small,  in  some  cases  so  small  that  the 
percentages  are  hardly  worth  considering.  In  general,  it  would 
appear  that  from  20  to  40  per  cent  of  cases  needing  treatment 
received  it. 

In  Pasadena,  California,  during  the  same  year,  the  propor- 
tions of  cases  treated  were  not  very  different.  The  report  of 
action  taken  is  as  follows: 

TABLE  23. — PHYSICAL  DEFECTS  REPORTED  AND  NUMBER  AND  PER 
CENT  OF  THESE  DEFECTS  TREATED.   PASADENA,  CAL., 


Defect 

Cases  reported 

Cases  treated 

Per  cent  treated 

Eyes    
Ears    
Nose    
Throat        
Teeth  
Nutrition    
Nervous  system 

685 
117 

202 
240 
1,230 

195 

48 

242 

21 
69 
91 

3P 
64 

12 

35 

18 

? 

30 
33 
25 

Total       

2,717 

874 

32 

94 


RESULTS 


From  Summit,  New  Jersey,  comes  a  report  of  the  numbers 
of  cases  discovered,  the  number  referred  to  a  physician,  and  the 
cases  in  which  a  physician  was  consulted. 

TABLE    24. — DEFECTS    REPORTED,    NUMBER    REFERRED    TO    PHYSI- 
CIANS,   AND    PER   CENT   OF   THESE    IN    WHICH    PHYSICIAN    WAS 
CONSULTED.      SUMMIT,  N.  J.,  1909-10 


Per  cent  of 

Defect 

Cases 
reported 

Cases 
referred 
to  phy- 
sician 

Cases  in 
which 
physician 
was 
consulted 

cases  refer- 
red to  physi- 
cian in 

which  phy- 
sician was 

consulted 

Defective  vision   . 

185 

132 

79 

60 

Defective  hearing 

21 

10 

8 

80 

Hypertrophied  tonsils 

124 

43 

12 

28 

Adenoids       .... 

35 

18 

6 

33 

Defective  teeth     . 

383 

I  12 

44 

39 

Total  

748 

315 

149 

47 

The  striking  feature  of  this  report  is  the  large  proportion 
of  cases  discovered  which  were  not  considered  important  enough 
to  be  referred  for  treatment.  It  is  to  be  assumed  that  all  cases 
regarded  as  needing  treatment  were  referred.  The  percentage 
of  eye  and  ear  cases  in  which  physicians  were  consulted,  based  upon 
the  numbers  referred,  is  much  higher  than  in  Harrisburg  or  Pasa- 
dena; but  the  number  of  cases  under  the.  head  of  "hearing"  is 
so  small  that  discussion  as  to  their  disposition  is  hardly  worth 
while. 

INTER-CITY  COMPARISONS 

The  foregoing  data,  cited  from  the  reports  of  the  different 
cities,  give  a  general  idea  of  the  degree  to  which  inspection  for 
the  detection  of  physical  defects  results  in  remedial  treatment. 
It  must  be  remembered  that  these  data  are  gathered  from  cities 
where  the  problem  has  been  given  special  attention  and  undoubt- 
edly reflect  conditions  distinctly  better  than  the  average.  When 
the  figures  from  four  of  the  cities  are  brought  together  the  result 
is  as  shown  in  the  following  table: 

95 


MEDICAL    INSPECTION    OF    SCHOOLS 


TABLE  25. — DEFECTS   REPORTED  AND  THE   NUMBER  AND    PER  CENT 
OF  THESE  DEFECTS  TREATED,  IN  FOUR  CITIES 


City  and  year 

Dejects 
reported 

Defects 
treated 

Per  cent 
treated 

New  York  City,  191  1  . 

234,349 

87,765 

37 

Pasadena,  Gal.,  1909-10 

2,717 

874 

32 

Harrisburg,  Pa.,  1909-10     . 

2,627 

923 

35 

Summit,  N.  J.,  1909-10 

748 

149 

20 

Several  other  cities  report  the  number  of  children  given 
remedial  treatment,  rather  than  the  number  of  defects  remedied. 
These  figures  reduced  to  percentages  for  three  cities  are  as  follows : 


St.  Louis,  Mo.,  1909-10  . 
Trenton,  N.  J.,  1909 
Oakland,  Gal.,  1910-11    . 


24  per  cent 
39  per  cent 
52  per  cent 


As  has  been  noted,  statements  as  to  improvement  resulting 
from  treatment  are  rare.  In  Trenton,  according  to  the  report 
referred  to  above,  172  out  of  the  190  children  treated  were  "im- 
proved/' Our  ignorance  as  to  kinds  of  defects  included,  nature 
of  treatment,  and  standards  by  which  improvement  was  judged, 
makes  the  statement  of  slight  value. 

TREATMENT  BY  PHYSICIANS  AND  INSTITUTIONS 
Statements  with  regard  to  the  agency  from  which  treatment 
was  obtained  are  made  by  two  cities — New  York  and  St.  Louis. 
Those  for  New  York  are  as  follows: 

TABLE    26. — CASES    OF    PHYSICAL    DEFECTS    TREATED    BY    PRIVATE 
PRACTITIONERS  AND  BY  INSTITUTIONS,  NEW  YORK,  IQI  I 


Defect 

Cases  treated  by 
•private  practitioners 

Cases  treated  by 
institutions 

Glasses     . 
Operative 
Medical    . 
Physical  culture     . 
Instructions    . 
Extraction  of  teeth 
Filling  teeth    . 

• 

5,530 
9,777 
20,604 

17 
836 

1,222 

5,666 
1  0,048 
10,684 
42 
341 
232 
151 

Total    . 

37,986 

27,164 

96 


RESULTS 


The  St.  Louis  report  for  1910-11  states  that  during  that 
school  year  the  number  of  cases  treated  by  family  physicians  or 
dentists  was  825  as  compared  with  1,088  cases  treated  at  free 
dispensaries  or  clinics. 


TREATMENT  FOLLOWING  EXAMINATIONS  BY  TEACHERS 

All  the  reports  thus  far  cited  have  been  of  results  following 
more  or  less  complete  physical  examinations  by  physicians. 
Two  Massachusetts  cities,  Lowell  and  Somerville,  offer  figures 
bearing  on  treatments  resulting  from  teachers'  examinations  of 
sight  and  hearing.  Lowell  reports  that  of  922  cases  of  defective 
eyes  and  ears  referred  to  parents  in  1910,  349,  or  37.8  per  cent, 
were  "professionally  treated/'  Somerville's  percentages  of  "pro- 
fessionally treated"  cases  during  five  successive  years  are  as 
follows : 


TABLE  27. — PERCENTAGES  OF  CASES  OF  DEFECTS  OF  EYES  AND  EARS 
TREATED    PROFESSIONALLY.      SOMERVILLE,    MASS.,    1906-10 


Defect 

1906 

1907 

1908 

1909 

1910 

Eyes      

25.3 

14.3 

24.9 

13.4 

10.8 

Ears      

20.9 

12.5 

10.2 

12.3 

12.3 

It  is  evident  that  a  larger  proportion  of  cases  received 
attention  in  the  first  year  in  Somerville  than  have  ever  been 
treated  since.  The  result  is  the  more  difficult  to  explain,  since 
the  percentage  of  children  examined  who  were  found  defective, 
both  in  eyes  and  ears,  has  steadily  decreased  from  year  to  year. 

Comparison  of  the  Somerville  and  Lowell  percentages  of  eye 
and  ear  treatments  with  the  data  'from  other  cities  already  cited 
reveals  the  fact  that  Lowell's  results  approximate  those  secured 
in  Harrisburg  and  Pasadena,  while  Somerville's  are  far  behind. 
This  contrast  may  be  due  to  the  fact  that  Somerville  is  the  only 
one  of  the  group  which  does  not  employ  a  nurse  or  home  visitor 
to  follow  up  cases  needing  attention. 
7  97 


MEDICAL    INSPECTION    OF    SCHOOLS 

The  diverse  reports  made  by  the  10  cities  mentioned  in 
this  chapter  indicate  that  anything  in  the  nature  of  a  general 
conclusion  as  to  the  value  of  results  achieved  by  medical  inspec- 
tion for  physical  defects  cannot  be  drawn.  It  is,  however,  safe 
to  assume  that  scarcely  any  American  city  has  yet  succeeded  in 
securing  the  benefits  of  genuine  treatment  for  as  many  as  half 
the  children  needing  it.  While  a  certain  irreducible  minimum  of 
defectiveness  must  doubtless  always  remain  uncorrected,  it  seems 
certain  that  this  minimum  has  nowhere  yet  been  reached. 

Doubtless  continuing  efforts  for  adjustment  will  result  in  the 
devising  of  new  methods  for  meeting  the  need.  One  of  the  most 
practicable  plans  now  being  urged  is  that  for  the  establishment 
of  school  dental  clinics,  which  is  discussed  in  another  chapter.* 
The  correction  of  all  dental  defects,  which  are  everywhere  the 
most  common  defects,  would  mean  a  long  step  in  advance.  The 
establishment  of  open  air  schools  for  tuberculous  and  anemic 
children  is  also  a  measure  the  effectiveness  of  which  has  been  abun- 
dantly demonstrated  in  many  cities  both  here  and  abroad. 

REPORTS  OF  TREATMENT  IN  ENGLISH  COMMUNITIES 

Reports  of  treatment  for  physical  defects  are  more  common 
in  England  than  in  this  country,  but  from  the  comments  of  the 
chief  medical  officer  of  the  board  of  education  it  is  evident  that 
there  is  some  uncertainty  as  to  what  is  meant  by  the  word 
"treatment."  In  his  report  for  1910  he  states  that  more  accurate 
description  of  results  cannot  be  achieved  "  until  the  report  on  the 
results  is  based  on  actual  re-examination  by  the  medical  officer." 
The  medical  officer  should  inform  himself  on  four  points: 

1.  Whether  treatment  was  obtained. 

2.  The  nature  of  the  treatment,  e.  g.,  whether  by  medication, the 
provision  of  food,  a  visit  to  a  convalescent  home,  or  the  performance  of  an 
operation. 

3.  By  what  agency  the  treatment  was  obtained,  e.  g.,  by  parent, 
nurse,  charitable  society,  private  practitioner,  at  the  hospital,  or  through 
the  Poor  Law. 

4.  The  exact  results  of  such  treatment,  or  the  causes,  so  far  as  can 
be  ascertained,  of  failure  to  obtain  treatment. 

*See  Chap.   IX,  p.   114. 


RESULTS 


Reported  treatments  are  tabulated  in  24  areas,  12  of  them 
counties,  12  of  them  boroughs  or  urban  areas.  The  defects  and 
diseases  reported  on  are:  defects  of  vision  (including  in  some  cases 
squint),  defects  of  the  external  eye,  of  tonsils  and  adenoids, 
defective  hearing,  ear  and  skin  diseases.  Not  all  of  these  defects 
are,  however,  reported  on  from  every  area.  Report  is  also  made 
from  some  areas  regarding  "  uncleanliness  and  vermin."  The 
figures  relative  to  these  conditions  are  omitted  in  the  accompany- 
ing summary: 

TABLE     28. — RECOMMENDATIONS      FOR     TREATMENT     BY     MEDICAL 
INSPECTORS  AND  NUMBER  AND   PER  CENT  OF  TREATMENTS   IN 
24  ENGLISH  AREAS. 


Cases 

Per  cent  of 

County  areas 

recommended 

Cases  treated 

recommended 

for  treatment 

cases  treated 

Anglesey         

374 

204 

54-5 

Devonshire     

2,525 

557 

22.1 

Ely,  Isle  of    

257 

144 

56.0 

Essex      

3>643 

i,735 

47.6 

Kent       

6,290 

2,502 

39-8 

Middlesex      

2,481 

1,169 

47.1 

Norfolk          1 

i,303 

692 

53-1 

Nottinghamshire  

626 

284 

45-4 

Surrey     

i,4'7 

688 

48.6 

Sussex  (West)        

505 

358 

70.9 

Worcestershire      

598 

419 

70.1 

Yorks  (East  Riding)     .... 

312 

,76 

56.4 

Total       

20,331 

8,928 

43-9 

Borough  and  Urban  Areas 

Beckenham        

204 

52 

25.5 

Blackburn  

803 

458 

57.0 

Darlington         

608 

281 

46.2 

Derby,  C.  B  

334 

83 

24.9 

Leicester,  C.  B  

1,235 

639 

5i-7 

Lincoln,  C.  B  

J33 

88 

06.2 

Middlesborough        .... 

992 

545 

54-9 

Morley        

350 

73 

20.9 

Penge  

179 

38 

21.2 

Salisbury    

202 

119 

58.9 

South  Shields     
Wolverhampton        .... 

732 
322 

420 
148 

57-4 
46.0 

Total       

6,094 

2,944 

48.3 

99 


MEDICAL   INSPECTION    OF    SCHOOLS 

It  would  appear  that  the  English  communities  are  con- 
siderably in  advance  of  those  of  the  United  States,  as  exactly 
12  out  of  the  24  included  in  this  summary  report  over  half  of 
their  defects  as  treated,  while  but  one  American  city  was  found 
which  reported  as  high  as  50  per  cent  of  treatments. 

SUMMARY. — American  cities  which  offer  statistical  reports 
regarding  defects  treated  are  exceptional.  Such  reports  as  are 
offered  show  roughly  from  1 1  per  cent  to  50  per  cent  of  treatments, 
figured  in  some  cases  on  a  basis  of  number  of  defective  children, 
in  others  on  a  basis  of  number  of  defects. 

Reports  from  England  are  far  more  numerous  and  show  a 
higher  range  of  percentages  treated — from  20  per  cent  to  70  per 
cent — while  the  average  for  24  areas  is  about  50  per  cent. 

Definitions  of  what  is  meant  by  "treatment"  are  seldom 
given  in  either  country,  but  such  evidence  as  exists  indicates 
that  the  figures  published  generally  tend  to  overstate  rather  than 
to  understate  the  proportion  of  cases  genuinely  treated. 


100 


CHAPTER  VIII 
PER  CAPITA  COSTS  AND  SALARIES 

SINCE  systems  of  medical  inspection  vary  in  scope  from 
vision  and  hearing  tests  conducted  by  teachers  to  complete 
physical  examinations  conducted  by  physicians,  and  because 
the  attendant  expense  may  range  anywhere  from  the  slight  cost 
of  printed  material  supplied  to  teachers  to  high  salaries  paid 
physicians  and  nurses,  it  follows  that  generalizations  concerning 
per  capita  costs  must  be  somewhat  indefinite. 

COST  OF  INSPECTION  FOR  CONTAGIOUS  DISEASE 
The  sort  of  medical  inspection  which  has  for  its  object  the 
discovery  of  incipient  cases  of  contagious  disease  and  their  exclu- 
sion from  school,  is  in  reality  merely  an  extension  of  the  work 
which  has  been  done  by  boards  of  health.  It  is  not  inherently 
expensive  in  terms  of  time  or  money.  In  most  cities  the  work  is 
carried  on  by  having  the  school  physicians  call  each  day,  or  two 
or  three  times  a  week,  and  inspect  the  children  referred  to  them 
by  the  teachers  as  seeming  to  be  in  ill  health,  or  who  have  returned 
to  school  after  an  unexplained  absence.  In  most  cases,  the 
physician  comes  at  stated  times,  without  being  notified.  In 
some  places  the  less  efficient  method  is  followed  of  having  the 
principal  notify  the  physician  by  telephone  when  he  is  wanted. 
The  annual  per  capita  cost  for  this  sort  of  medical  inspection 
averages  about  13  cents. 

COST  OF  VISION  AND  HEARING  TESTS  GIVEN  BY  TEACHERS 

By  far  the  least  expensive  of  all  systems  are  those  consisting 
solely  of  examinations  conducted  by  teachers  for  the  detection 
of  defects  of  vision  and  hearing.  They  are  prescribed  by  state 
law  or  regulation  in  Massachusetts,  Colorado,  Indiana,  Maine, 

101 


MEDICAL   INSPECTION   OF   SCHOOLS 

Minnesota,  Rhode  Island,  and  Utah,  and  are  conducted  without 
legal  enactment  in  many  towns  and  cities  of  other  states. 

The  only  expenses  incurred  in  such  examinations,  in  addition 
to  the  cost  of  the  teacher's  time,  are  for  printed  material  consisting 
of  directions,  test  cards,  record  blanks,  notices  to  parents,  etc. 
Even  for  a  large  number  of  children,  the  expense  is  low.  The 
amount  appropriated  by  the  Massachusetts  act  is  $800  per  year, 
and  of  this  appropriation  only  $592  was  actually  expended  in 
1910-11.  As  there  are  approximately  half  a  million  children  in 
the  public  schools  of  Massachusetts,  this  means  an  annual  per 
capita  expenditure  of  slightly  more  than  one  mill. 

In  Connecticut,  where  tests  of  vision  are  conducted  trien- 
nially,  the  total  expense  for  the  state  is  about  $700  for  each  test, 
which  means  a  per  capita  cost  of  nearly  one-half  cent. 

The  time  necessary  to  conduct  these  examinations  is  from 
three  to  five  minutes  per  pupil.  These  figures  show  that  both  in 
time  and  in  money,  the  necessary  expenditure  for  conducting 
vision  and  hearing  tests  by  teachers  is  slight. 

Such  tests  do  not  take  the  place  of  thorough  examinations 
by  competent  trained  experts.  It  cannot  be  gainsaid,  however, 
that  they  are  of  great  and  real  value,  and  it  is  to  be  doubted 
whether,  in  the  whole  range  of  educational  endeavor,  there  can  be 
discovered  another  field  where  so  great  returns  for  good  are  to  be 
secured  at  so  small  an  expenditure  of  time  and  money. 


SALARIES  AND  PER  CAPITA  COST  FOR  SALARIES 

The  great  variation  in  the  amount  and  character  of  work 
done  in  different  systems  of  medical  inspection  renders  a  discus- 
sion of  salaries  most  difficult.  This  is  because  of  the  inherent 
difficulty  in  comparing  the  work  done  in  one  locality  per  unit 
of  salary  with  that  performed  in  another.  An  idea  of  the  salaries 
paid  to  school  physicians  and  nurses  in  American  cities  may  be 
gained  from  Table  29.*  This  table  presents  conditions  in  1911 
in  77  American  cities  of  more  than  8,000  population  where  the 
work  was  conducted  under  the  auspices  of  the  board  of  educa- 
tion. Data  are  taken  from  the  investigation  conducted  by  the 

*See  p.  104  if. 
I O2 


The  equipment  of  this  Rochester  dental  clinic  cost  about  $700. 


Dental  treatment  costs  less  than  the  extra  schooling  bad  teeth  involve. 


PER   CAPITA   COSTS    AND   SALARIES 

Russell  Sage  Foundation  in  the  spring  of  1911,  and  the  figures 
for  attendance  are  taken  from  the  report  of  the  United  States 
Commissioner  of  Education  for  the  year  1909-10.  Data  have 
been  restricted  to  the  cities  where  the  work  is  conducted  under 
the  department  of  education,  because  it  is  frequently  the  case 
in  systems  under  the  board  of  health  that  part  of  the  salary 
paid  is  in  return  for  other  sorts  of  inspection  work  conducted  for 
the  board  of  health. 

It  will  be  noted  that  the  per  capita  figures  presented  in  the 
table  refer  only  to  expenditures  for  salaries  of  inspectors  and 
nurses  and  do  not  take  into  account  sums  paid  for  printing, 
supplies,  equipment,  and  so  forth.  Cities  where  the  systems  of 
medical  inspection  do  not  include  examinations  for  physical 
defects  are  indicated.  All  other  rates  thus  apply  to  relatively 
complete  systems,  including  physical  examinations  as  well  as 
inspections  for  the  detection  of  contagious  disease. 

In  the  52  cities  where  physical  examinations  are  conducted, 
the  average  per  capita  rate  is  24  cents,  while  in  the  other  25  cities 
it  is  slightly  over  13  cents.  Only  six  cities  pay  more  than  50  cents 
per  child  for  medical  inspection,  and  of  these,  two  are  in  California 
and  four  in  New  Jersey.  Unfortunately,  it  is  impossible  from  the 
data  at  hand  to  determine  a  minimum  per  capita  rate  for  efficient 
medical  inspection  including  adequate  follow-up  work.  It  is 
worthy  of  note,  however,  that  among  the  19  cities  listed  in  this  table 
employing  school  nurses  the  average  per  capita  rate  is  30  cents, 
and  it  is  probable  that  this  sum  may  fairly  be  regarded  as  a  mini- 
mum for  securing  an  adequate  and  efficient  system. 

SALARIES  OF  SCHOOL  PHYSICIANS  AND  NURSES 
Professor  William  Osier  is  credited  with  saying,  as  already 
quoted,  in  regard  to  the  work  of  medical  inspection  in  England : 
"  If  we  are  to  have  school  inspection,  let  us  have  good  men  to  do 
the  work  and  let  us  pay  them  well.  It  will  demand  a  special 
training  and  a  careful  technique/'  It  is  certainly  to  be  regretted 
that  this  point  of  view  has  not  been  more  generally  taken  in  Amer- 
ica. In  this  country  the  financial  remuneration  of  school  physi- 
cians and  school  nurses  is  almost  invariably  inadequate.  The 
salaries  paid  range  from  nothing  to  $4,000  per  annum. 

103 


MEDICAL   INSPECTION    OF   SCHOOLS 


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107 


MEDICAL    INSPECTION    OF    SCHOOLS 


In  many  localities  the  local  medical  association  conducts  in- 
spection for  a  year  or  two  without  cost  to  the  city  in  order  to 
demonstrate  its  value.  This  is  why  the  tabulated  returns  show 
that  in  a  considerable  number  of  cities  the  physicians  and  nurses 
receive  no  pay.  It  may  also  be  a  factor  in  bringing  about  the  ex- 
tremely low  salaries  that  are  received  after  regular  payment  is 
given. 

The  following  table  is  made  up  from  the  study  of  condi- 
tions in  1,038  cities  and  shows  the  number  reporting  salaries  in 
which  the  salaries  of  physicians  and  nurses  fall  within  the  limits 
named  in  each  group.  That  is  to  say,  the  first  line  shows  that 
there  are  75  cities  in  which  the  physicians  give  their  services  and 
21  in  which  the  school  nurses  do  the  same.  The  second  line 
indicates  that  there  are  47  cities  in  which  the  salaries  paid  to  the 
physicians  are  between  $i  .00  and  $100  per  annum,  and  so  on. 

TABLE  30. — ANNUAL  SALARIES  OF  PHYSICIANS  AND  NURSES  IN  ALL 
CITIES  REPORTING 


Cities  in  which 

Cities  in  which 

Annual  salary 

physicians  receive 

nurses  receive  salary 

salary  indicated 

indicated 

No  salary 

75 

21 

$I-$IOO      . 

47 

$IOI-$2OO      . 

5° 

$20  I  -$300      . 

44 

2 

$30  I  -$400      . 

25 

$40I-$500      . 

24 

I 

$5oi-$6oo    .       . 

18 

21 

$60  I  -$700    . 

2 

17 

$70I-$800   . 

12 

24 

$80  I  -$900   . 

6 

15 

$901-^1,000 

13 

2 

$  i,  ooi-$  i,  500 

18 

2 

$i,50i-$2,500 

7 

.  . 

$3,500-$4,ooo 

3 

.  . 

Fees  according  to  service 

19 

I 

Total        

363 

1  06 

The  table  shows  that  there  are  more  cities  paying  their 
school  physicians  at  the  rate  of  between  $100  and  $200  per  year 

1 08 


PER   CAPITA   COSTS    AND    SALARIES 

than  there  are  paying  salaries  of  any  other  amount.  On  the  other 
hand,  the  average  salary  is  somewhat  higher  than  this.  If  com- 
puted on  the  basis  of  the  table,  without  taking  into  account  the 
number  of  physicians  employed  in  each  individual  city,  the  average 
salary  would  fall  within  the  group  receiving  from  $201  to  $300. 

Of  course  the  sum  of  $200  per  annum  paid  to  school  physi- 
cians is  given  in  return  for  only  a  part  of  their  time.  Never- 
theless, it  has  come  to  be  regarded  as  a  somewhat  standard  rate 
of  remuneration  for  school  physicians  all  over  America.  There  are 
cases  where  so  little  work  is  required  that  this  amount  may  be 
considered  adequate,  but  undoubtedly  in  most  cases  it  represents 
either  an  undue  degree  of  sacrifice  on  the  part  of  the  school 
physician  or  inadequate  work. 

That  the  words  of  the  eminent  Oxford  professor  have  been 
heeded  in  his  own  country  seems  evident  from  the  salaries  paid 
to  the  medical  inspectors  of  schools  in  England.  Almost  without 
exception  salaries  are  appreciably  higher  than  those  paid  in  America, 
and  more  liberal  provision  is  made  for  clerk  hire  and  for  meet- 
ing incidental  expenses.  Indeed,  the  undoubted  fact  is  that  the 
whole  movement  has  been  placed  on  a  higher  plane  in  England 
than  in  the  United  States.  Nevertheless,  the  situation  in  England 
with  respect  to  remuneration  for  school  medical  work  is  still  such 
as  to  call  forth  much  criticism  from  the  British  medical  societies. 
It  appears  that  the  dominant  idea  at  the  time  that  medical 
inspection  was  inaugurated  under  the  board  of  education  was  that 
inspectors  should  be  paid  at  the  rate  of  from  25  to  60  cents  for 
each  child  examined.  However,  no  definite  financial  standard  was 
established  and  much  dissatisfaction  has  resulted.  The  British 
Medical  Association  recently  took  up  the  subject  and  attempted 
to  formulate  a  standard  which  may  be  summarized  as  follows:* 

Payment  to  be  based  on  time  spent  in  school  work  (including 
advisory  and  supervisory  work),  not  on  number  of  children  examined. 

Salary  for  part-time  oificers:  $250  per  annum  for  one  session  per 
week,  or  $200  per  annum  in  the  case  of  inexperienced  beginners.  (Women 
to  receive  same  salaries  as  men.) 

Not  less  than  $2,500  per  annum  for  experienced  whole-time  officers; 
young  assistants,  $1,250  to  $1,500  per  annum. 

*  Hogarth,  A.  H.:  Medical  Inspection  of  Schools,  p.  136.  London,  Henry 
Frowde,  Oxford  University  Press,  1909. 

109 


MEDICAL    INSPECTION    OF    SCHOOLS 

In  many  instances  salaries  are  now  paid  on  a  scale  equal 
to  that  indicated.  Thus  the  town  of  Guilford,  England,  has 
appointed  a  chief  medical  officer  at  $3,000  to  be  increased  to  $4,000 
by  equal  increments,  and  four  assistants  at  $1,250  each,  besides 
an  allowance  of  $200  to  each  physician  for  traveling  expenses. 
Northampton  has  employed  two  inspectors  at  $1,500;  Stafford 
has  one  at  $1,515  and  three  at  $1,250,  with  provision  for  increase 
to  $1,500  and  for  payment  of  expenses  and  clerical  assistance. 
It  must  be  remarked  in  considering  these  English  salaries  that  the 
amounts  paid  represent  relatively  greater  incomes  than  do  the 
same  sums  in  America.  Moreover,  the  English  code  provides  for 
but  three  physical  examinations  in  the  course  of  the  school  life  of 
the  child,  whereas  the  Massachusetts  law,  where  the  standard 
salary  of  the  school  physicians  is  $200  per  year,  requires  that  such 
a  complete  physical  examination  of  each  child  be  made  every  year. 


COST  OF  CLERICAL  ASSISTANCE 

A  feature  of  the  financial  administration  of  medical  inspec- 
tion which  has  received  adequate  attention  abroad,  but  which  has 
been  almost  entirely  neglected  here,  is  that  of  furnishing  medical 
inspectors  with  adequate  clerical  assistance.  In  the  nature  of 
the  case,  the  work  requires  the  making  of  a  great  many  entries 
on  individual  record  cards  or  sheets;  and  upon  the  thoroughness 
and  system  with  which  this  is  done  depends  to  a  large  degree  the 
eificacy  of  the  work.  Recent  careful  timing  of  work  done  by  one 
of  the  most  skilful  examiners  in  the  employ  of  the  New  York  City 
board  of  health  shows  that  it  took  him  on  the  average  about 
twelve  minutes  to  make  each  physical  examination.  Half  of 
this  time  was  employed  in  conducting  the  examination  itself  and 
the  other  half  was  spent  in  the  purely  clerical  work  of  entering 
results  on  the  sheets.  The  very  writing  of  the  names  of  the 
pupils  on  their  individual  record  cards  and  those  of  the  parents  on 
notification  cards  often  consumes  a  great  deal  of  time  in  some 
quarters  of  the  city,  and  constitutes  a  class  of  work  which  ought 
not  to  be  foisted  upon  a  trained  physician.  Here  are  some 
names  taken  more  or  less  at  random  from  the  school  registers  in  a 
Polish  section: 

no 


PER   CAPITA   COSTS    AND    SALARIES 

Rzemieszkievicz  Klymezynski 

Zdrojewski  Wrzesimski 

Gorzelanczyk  Guleszecwicz 

When  a  physician  is  being  paid  at  the  rate  of  from  $1.00  to  $2.00 
per  hour,  it  is  certainly  a  most  unbusinesslike  and  inefficient 
policy  to  require  him  to  spend  half  of  his  time  doing  work  which  a 
clerk  at  $12  or  $15  a  week  could  perform  equally  well.  The 
physician  above  mentioned  said  in  answer  to  a  query  that  he  felt 
sure  he  could  examine  twice  as  many  children  in  the  given  time 
if  he  had  the  help  of  a  clerk,  and  that  he  would  find  the  work  much 
more  agreeable.  This  is  a  matter  which  demands  attention 
wherever  systems  of  medical  inspection  are  to  be  installed.  It 
is  at  present  one  of  the  weak  points  of  all  American  systems. 

EQUIPMENT 

FOR  SCHOOL  PHYSICIANS 

The  following  statements  concerning  the  necessary  equip- 
ment for  school  physicians  and  school  nurses  are  taken  from  an 
article*  published  in  1911  by  Dr.  George  J.  Holmes,  Supervisor  of 
Medical  Inspection  of  Newark,  N.  J.  They  are  based  upon  ex- 
tended and  successful  experience. 

The  school  physician's  room  should  be  "well  lighted,  painted 
white  or  light  colored,  wood  floor."  It  should  contain  the  follow- 
ing equipment: 

One  or  two  small,  flat-top  tables  with  a  drawer,  painted  white 
enamel 

Chairs  rather  than  benches 

Wash  basin  and  running  water 

Paper  towels 

White  enamel  pail  for  waste  materials 

Screen 

Window  shades  operated  from  below  upward 

Wooden  tongue  depressors 

Eye  charts  (Snellen's  and  illiterate) 

Medical  cabinet  of  wood,  with  lock  and  key  for  medical  and  surgi- 
cal supplies  of  nurses  and  physicians 
*  Journal  of  the  Medical  Society  of  New  Jersey,  1911 
III 


MEDICAL   INSPECTION    OF    SCHOOLS 

File  boxes  and  index  for  filing  physical  examination  cards 
Absorbent  cotton,  bandages,  alcohol,  bichloride  tablets,  tincture 

of  green  soap,  quart  jar  with  screw  top  for  bandages  and 

dressings 
Full  list  of  printed  forms  used  by  inspectors 

FOR  SCHOOL  NURSES 
The  following  is  a  list  of  supplies  used  by  nurses  in  schools: 

Absorbent  cotton,  ^  Ib.  pkg.  Lysol 

Adhesive  plaster,  2  in.  by  10  yds.  Sulphur  ointment 

Alcohol,  grain,  95  per  cent  Sweet  oil 

Bandages,  i  in.  by  10  yds.,  Linton  Stearate  of  zinc  (powder,  in  boxes) 

gauze  White  precipitate 

Bandages,  2  in.  by  10  yds.,  Liriton  Zinc  ointment 

gauze  Bottles,  4  oz.,  with  corks 

Plain  gauze,  i  yd.  long,  i  yd.  wide  Ciliary  forceps  No.  1,628 

Argyrol,  5  per  cent  Clinical  thermometers 

Bichloride  tablets,  7^  gr.  Ointment  jars,  4  oz. 

Flexible  collodion  Tooth  picks 

Iodine,  tincture  Full  list  of  printed  forms  used 


SUMMARY. — In  summing  up  the  problems  of  administration 
which  relate  to  expense  it  can  only  be  said  that  in  this,  as  in  all 
other  branches  of  organized  endeavor,  cost  varies  with  the  extent 
and  kind  of  work  done.  Examinations  by  teachers  for  the  dis- 
covery of  defects  of  vision  and  hearing  involve  only  the  added 
expense  of  the  simple  printed  material  required.  Inspection  by 
physicians  for  the  detection  of  contagious  diseases  is  inexpensive 
and  of  great  value  in  its  results. 

Systems  of  medical  inspection  which  include  careful  physical 
examinations  of  all  children  cost  the  most  and  are  by  far  the  most 
valuable.  From  a  social  and  economic  point  of  view  they  are  by 
far  the  cheapest  in  the  better  sense  of  the  word,  as  they  are  the 
most  far-reaching  both  in  their  immediate  and  in  their  indirect 
results. 

If,  however,  a  system  of  medical  inspection  is  to  be  efficient 
and  effective  for  any  considerable  length  of  time,  it  is  clear  that 
adequate  salaries  must  be  paid  to  those  in  charge  of  the  work. 

1 12 


PER   CAPITA   COSTS   AND    SALARIES 

Efficient  work  can  not  long  be  expected  from  volunteers, 
and  perhaps  even  less  will  it  be  given  by  physicians  who  receive 
a  bare  pittance  in  return  for  their  time  and  skill.  Neither  can 
it  be  expected  that  first  class  men  will  long  be  content  to  spend 
the  greater  part  of  their  time  in  doing  the  purely  clerical  work 
of  filling  out  blanks  in  duplicate  and  triplicate. 

Permanent  efficiency  will  require  skilled  workers,  careful 
administration,  and  adequate  remuneration. 


CHAPTER  IX 
DENTAL  INSPECTION 

DR.  WILLIAM  OSLER  is  credited  with  saying,  "If  I  were 
asked  to  say  whether  more  physical  deterioration  was 
produced  by  alcohol  or  by  defective  teeth,  I  should  say 
unhesitatingly,  defective  teeth/'  The  history  of  the  movement  for 
dental  inspection  of  school  children  shows  that  during  the  past  decade 
educators  and  hygienists  all  over  the  world  have  been  awakening  to 
a  realization  of  the  truth  and  significance  of  Dr.  Osier's  statement. 

Although  the  development  of  dental  inspection  both  in 
America  and  abroad  has  come  almost  entirely  within  the  past 
decade,  the  beginnings  date  back  more  than  a  quarter  of  a  century. 
So  far  as  is  known  the  first  free  dental  clinic  in  the  world  was 
established  in  Rochester,  New  York,  more  than  twenty-five  years 
ago.  While  this  was  not  strictly  a  school  clinic,  work  with  children 
was  done  and  the  present  movement  might  have  had  its  inception 
there  had  not  lack  of  support  resulted  in  the  closing  of  the  clinic 
after  some  two  years  of  existence. 

Fifteen  years  later  dental  work  for  school  children  was 
seriously  started  in  Germany  and  was  soon  followed  by  similar 
work  in  England,  in  the  United  States,  and  to  some  extent  in 
other  countries. 

The  movement  owes  its  rapid  development  to  the  world- 
wide awakening  to  the  importance  of  dental  conditions  and  still 
more  directly  to  the  publication  of  the  findings  of  school  physicians 
employed  in  the  work  of  medical  inspection.  These  reports  have 
shown  with  convincing  consistency  that  a  large  proportion  of 
all  school  children  are  suffering  from  decayed  teeth.  These 
results  come  from  all  civilized  countries  and  reveal  especially 
serious  conditions  in  the  poorer  quarters  of  our  great  cities. 

Thus  Unghavari  reported*  as  a  result  of  his  studies  of 
dental  conditions  among  school  children  in  Hungary  that  87  per 

*  Unghavari  (Hungarian  physician):  A  study  in  Scedegin.  Referred  to  by 
W.  H.  Burnham  in  Hygiene  of  the  Teeth,  Pedagogical  Seminary,  September,  1906, 
P-  293- 

114 


Too  late  for  effective  treatment. 


Each  missing  upper  tooth  renders  useless  the  corresponding  lower  tooth. 


DENTAL    INSPECTION 

cent  had  diseased  teeth.  An  extensive  investigation  in  Prussia* 
showed  that  among  almost  20,000  children  in  19  cities,  95  per  cent 
were  afflicted  with  dental  caries.  Dr.  Heniej  examined  school 
children  in  Norway  and  found  97  per  cent  with  decayed  teeth. 
Investigations  conducted  in  Dunfermline,  Scotland, J  showed  that 
96  per  cent  of  the  children  needed  dental  attention.  Among 
2,200  pupils  in  the  public  schools  not  a  single  child  was  found  who 
had  had  dental  care  or  whose  teeth  were  filled  or  otherwise  attended 
to.  In  America  conditions  are  little  if  any  better  than  abroad. 

The  serious  significance  of  dental  conditions  existing  among 
school  children  in  a  typical  American  city  may  be  appreciated  by 
studying  the  record  of  the  examination  of  447  school  children 
ranging  in  age  from  six  to  sixteen  years  in  Elmira,  New  York. 
These  children  were  examined  by  local  dentists  in  I9io.§  The 
findings  are  given  in  Table  3 1 . 

TABLE    31. — RESULTS    OF    DENTAL    INSPECTION    OF    447    CHILDREN, 
AGES  SIX  TO  SIXTEEN,  ELMIRA,  NEW  YORK,   1910 

No.  of  children  examined 447 

No.  of  children  with  teeth  in  perfect  condition  .  22 

No.  of  cavities  needing  filling 2063 

No.  of  teeth  and  roots  needing  extraction  .        . 617 

No.  of  children  needing  teeth  cleaned 425 

No.  of  children  needing  gums  treated 18 

No.  of  children  suffering  with  pus-discharging  abscesses 15 

No.  of  children  in  need  of  surgical  treatment  for  irregular  teeth     ...         60 

No.  of  teeth  prematurely  lost  by  extraction 315 

No.  of  children  with  malocclusion 9 

No.  of  children  using  tooth  brush  daily  (condition  of  mouths  did  not  verify 

this  claim) 127 

No.  of  children  who  had  been  to  a  dentist  (in  most  cases  for  extractions  only)       100 

182  or  40  per  cent  of  the  children  had  fairly  good  masticating  capacity. 

1 19  or  27  per  cent  of  the  children  had  three-fourths  masticating  capacity. 

106  or  24  per  cent  of  the  children  had  one-half  masticating  capacity. 
38  or  8  per  cent  of  the  children  had  one-fourth  masticating  capacity. 
2  children  had  no  masticating  capacity. 

*  Investigation  made  by  an  association  of  dentists  in  the  province  of  Schles- 
wig-Holstein.  Zeitschrift  fur  Schulgesundheitspflege,  No.  7,  1900.  Referred  to 
by  W.  H.  Burnham,  op.  cit. 

t  Dr.  C.  Henie  (School  physician  in  Hamar,  Norway) :  Untersuchungen 
iiber  die  Zahne  der  Volksschiiler  zu  Hamar  in  Norwegen.  Zeitschrift  fur  Schulge- 
sundheitspflege, February,  1898,  Vol.  II,  pp.  65-71.  Referred  toby  W.  H.  Burn- 
ham,  op.  cit. 

t  Second  Annual  Report  on  the  Medical  Inspection  of  School  Children  in 
Dunfermline,  Scotland,  1907,  pp.  12-14. 

§  Annual  Report  of  Don  C.  Bliss,  Superintendent  of  Schools,  Elmira,  N.  Y., 
1909-10,  p.  30  ff. 


MEDICAL    INSPECTION    OF    SCHOOLS 

The  importance  of  these  conditions  is  emphasized  by  a  mass 
of  information  showing  with  startling  distinctness  that  as  civiliza- 
tion advances  human  teeth  tend  to  become  less  efficient  and  even 
to  disappear.  According  to  Dr.  Rose*  only  about  2  per  cent  of 
the  Eskimos  have  defective  teeth,  3  to  10  per  cent  of  the  American 
Indians,  3  to  20  per  cent  of  Malays,  40  per  cent  of  Chinese,  and  80 
to  96  per  cent  of  Europeans  and  Americans.  There  is  evidence 
showing  that  for  centuries  the  lower  face  and  jaws  of  civilized  man 
have  been  deteriorating.  An  examination  of  402  British  soldiers! 
revealed  the  fact  that  only  eight  had  a  width  of  jaw  equal  to  the 
average  jaw  width  of  the  Roman  soldier.  The  average  American 
jaw  has  been  found  to  be  more  than  one-third  of  an  inch  narrower 
than  that  of  the  ancient  Roman.  These  facts  mean  that  we  are 
here  dealing  with  a  problem  in  which  we  must  do  far  more  than 
merely  let  nature  have  her  own  way  if  we  are  to  conserve  normal 
healthy  conditions. 

There  is  another  mass  of  evidence  tending  to  show  in  definite, 
quantitative  terms  the  importance  of  good  teeth  among  school 
children.  In  Chapter  XI,  on  Physical  Defects  and  School  Prog- 
ress, are  quoted  data  taken  from  an  investigation  in  New  York 
City  which  showed  that,  on  the  average,  children  having  defective 
teeth  take  one-half  a  year  longer  to  complete  the  elementary 
school  course  than  do  children  not  so  afflicted. 

In  the  Nineteenth  Century  for  July,  1899,  Dr.  Collinsf  reports 
an  investigation  indicating  that  children  with  good  teeth  stand 
appreciably  higher  in  scholarship  and  school  promotion  than  do 
those  having  poor  teeth. 

In  1901,  Dr.  Johnson  conducted  an  investigation  in  the 
schools  of  Andover,  Massachusetts,!  which  showed  that  in  physi- 
cal development  as  indicated  by  weight,  children  with  good  teeth 
were  on  the  average  about  half  a  year  ahead  of  children  with  poor 

*  Dr.  Karl  Rose,  Die  Zahnpflege  in  den  Schulen.  Zeitschrift  fur  Schulge- 
sundheitspflege,  1895,  Vol.  VIII,  pp.  65-87.  Referred  to  by  W.  H.  Burnham,  op. 
cit. 

f  Examination  of  British  and  American  Soldiers.  Referred  to  by  E.  S. 
Talbot:  Degeneracy,  Its  Causes,  Signs  and  Results.  Contemporary  Science  Series. 

J  Collins,  Dr.  Edwin:  The  Teeth  of  the  School  Boy.  Nineteenth  Century, 
July,  1899,  p.  84. 

§  Johnson,  Dr.  George  E.:  The  Condition  of  the  Teeth  of  School  Children 
in  Public  Schools.  Pedagogical  Seminary,  March,  1901,  pp.  45-58. 

116 


DENTAL    INSPECTION 

teeth.  Again,  Superintendent  Verplanck  of  South  Manchester, 
Connecticut,  reported  in  1910*  that  only  25  per  cent  of  the  children 
promoted  at  the  end  of  the  year  had  seriously  defective  teeth  as 
compared  with  38  per  cent  of  the  non-promoted  children. 

While  such  statistical  evidence  is  not  abundant,  the  data 
which  exist  show  consistently  a  relation  between  dental  conditions 
and  mental  ability. 

DENTAL  INSPECTION  ABROAD 

GERMANY 

The  first  dental  clinic  for  school  children  in  Germany  seems 
to  have  been  established  by  Dr.  Jessen  in  Strassburg  in  1902. 
From  its  inception  the  work  has  had  a  marked  success  and  has 
rapidly  grown.  At  present  Strassburg  has  a  $60,000  building  for 
a  school  dispensary.  The  children  are  examined  upon  their 
entrance  into  the  public  schools  and  twice  a  year  thereafter  until 
they  reach  the  age  of  thirteen.  The  treatment  furnished  includes 
cleaning,  fillings,  and  extractions.  Parents  able  to  pay  are  charged 
for  the  service,  but  the  most  necessitous  cases  are  treated  gratis 
and  the  deficit  is  made  up  by  the  municipality.  The  dentists 
are  state  officers  receiving  regular  salaries  and  are  not  permitted 
to  engage  in  private  practice.  One  feature  of  the  work  is  the 
supplying  of  tooth  brushes  to  all  patients. 

The  work  initiated  in  Strassburg  rapidly  spread  to  other 
German  cities  and  served  as  a  model  in  the  organization  of  many 
of  the  new  systems.  Cologne  established  a  dental  clinic  in  1908 
at  an  initial  cost  of  $5,500.  The  school  children  are  referred  to  the 
clinic  by  the  teachers  but  they  must  secure  the  consent  of  their 
parents  before  being  given  dental  treatment.  The  cost  of  main- 
tenance amounts  to  from  $6,000  to  $6,500  annually,  this  sum 
serving  to  meet  the  salary  expense  of  one  director  on  part  time, 
two  assistants  on  whole  time,  and  two  nurses  on  whole  time. 

In  the  city  of  Hamburg  work  was  begun  in  1911  in  connection 
with  the  dental  clinic  of  the  Municipal  Insurance  Committee. 
This  clinic  occupies  twelve  rooms  and  was  designed  to  provide 

*  Annual  Report  of  Fred.  A.  Verplanck,  Superintendent  of  Schools,  South 
Manchester,  Conn.,  1910,  p.  37. 


MEDICAL    INSPECTION    OF    SCHOOLS 

dental  attention  for  domestic  servants  receiving  the  benefits  of 
compulsory  industrial  insurance.  It  was  found  that  the  force  and 
equipment  were  so  ample  that  other  work  could  be  undertaken 
and  the  clinic  arranged  to  treat  40  school  children  per  day.  Its 
support  is  guaranteed  by  a  municipal  appropriation  of  $2,000  per 
year  for  the  three  years  1911-14.  The  children  treated  are 
referred  to  the  clinic  by  the  school  physicians. 

In  all,  some  78  German  cities  and  towns  give  some  kind  of 
dental  treatment  to  school  children.  Of  these  78  localities,  70 
are  cities  of  more  than  10,000  population.  The  fact  that  the 
remaining  eight  cities  have  populations  of  less  than  10,000  indi- 
cates that  in  Germany  they  have  begun  to  realize  that  dental 
inspection,  like  medical  inspection,  is  no  less  important  in  the  small 
towns  and  rural  districts  than  it  is  in  the  great  centers  of  popula- 
tion. In  about  30  localities  the  authorities  have  come  to  regard 
dental  treatment  as  a  necessary  accompaniment  of  education 
and  have  made  it  free  and  universal.  In  twelve  localities  a  more 
conservative  course  is  followed  and  free  treatment  is  furnished  poor 
children  only.  A  still  more  conservative  attitude  is  represented 
by  the  course  followed  in  26  cities  where  the  parents  make 
small  annual  payments  for  the  treatment  furnished  their  children. 
These  annual  contributions  vary  in  amount  from  12  to  50  cents 
per  child. 

Of  the  78  school  dental  clinics  in  the  Empire  38  are  municipal, 
three  are  attached  to  universities,  three  are  in  private  hands,  and 
the  remaining  34  are  conducted  by  dentists  who  give  part-time 
service.  The  clinics  vary  in  size  from  small  ones  of  one  or  two 
rooms  to  those  in  Strassburg  and  Hamburg  containing  10  and  12 
rooms  respectively. 

There  are  three  general  plans  of  administration.  In  the 
first  the  dental  clinic  is  maintained  by  the  school  authorities  as 
an  integral  part  of  the  educational  system.  In  the  second  the 
clinics  are  supported  by  means  of  municipal  grants  to  local  dental 
associations.  In  the  third,  commonly  adopted  in  smaller  com- 
munities, arrangements  are  made  with  private  dentists  whereby 
school  children  needing  treatment  are  sent  to  them  on  certain 
specified  days. 

The  dental  clinic  has  passed  the  experimental  stage  in 

118 


DENTAL    INSPECTION 

Germany.  In  no  part  of  the  public  medical  service  have  such 
valuable  results  been  obtained  through  the  expenditure  of  such 
small  funds.  The  experience  of  many  cities  demonstrates  that 
the  health  of  the  children  has  been  markedly  improved  by  dental 
treatment  and  that  the  work  has  been  of  genuine  value  in  the 
campaign  against  tuberculosis  and  contagious  disease.  The 
number  of  children  requiring  treatment  each  year  is  steadily 
declining,  and  with  the  development  of  better  conditions  the  num- 
ber of  extractions  is  becoming  constantly  smaller.  Moreover, 
both  children  and  parents  appreciate  the  value  of  the  dental  work 
and  voluntarily  apply  for  treatment  instead  of  having  to  be  urged 
to  submit  to  it  as  was  formerly  the  case. 

ENGLAND 

In  England  the  first  dental  clinic  was  started  in  Cambridge 
in  1907  as  a  private  venture.  Two  years  later  the  work  was  taken 
over  by  the  city.  At  the  present  time  provisions  for  the  dental 
treatment  of  school  children  are  made  in  16  cities.  In  three  of 
these  the  clinic  is  connected  with  a  public  infirmary  and  sup- 
ported by  municipal  contribution.  In  12  cities  the  dental  clinics 
are  supported  by  separate  institutions,  and  in  five  of  these  cases 
the  dentists  are  employed  on  whole  time  and  in  the  other  seven 
on  part  time.  One  city  employs  part-time  dentists  but  does  not 
support  a  clinic. 

Perhaps  the  most  significant  and  interesting  school  dental 
work  now  being  carried  on  in  England  is  that  conducted  by  the 
county  of  Somerset.  In  that  county  ten  dentists  are  employed 
to  care  for  the  teeth  of  children  in  the  villages  and  country  districts 
as  well  as  in  the  larger  towns.  They  are  paid  at  the  rate  of  $7.50 
per  six-hour  day  and  are  allowed  to  give  their  time  in  either 
whole  or  half  days.  They  are  allowed  12  cents  for  material  for 
each  child  treated  and  are  granted  allowances  to  cover  reasonable 
traveling  expenses.  Wherever  possible  the  work  is  done  in  the 
private  office  of  the  dentist,  and  where  this  cannot  be  arranged 
the  school  authorities  set  aside  a  room  for  the  purpose.  The 
instruments  and  appliances  are  supplied  by  the  dentists. 

Conditions  among  the  English  children  have  been  found  so 
serious  that  in  general  the  object  of  the  work  is  to  prevent  the 

119 


MEDICAL    INSPECTION    OF    SCHOOLS 

progress  of  dental  deterioration  rather  than  to  cure  the  already 
existing  conditions.  The  problem  is  to  administer  a  limited  force 
and  limited  funds  so  as  to  do  the  greatest  permanent  good  to  the 
greatest  possible  number  of  children.  The  solution*  has  been 
found  through  beginning  with  the  youngest  children  and,  after 
once  treating  a  child,  assuming  the  responsibility  for  keeping 
its  permanent  teeth  in  good  condition.  This  plan  makes  it 
possible  to  advance  the  age  limit  of  caring  for  the  children  annually 
by  one  year,  and  in  a  few  years  will  make  it  possible  to  include 
all,  the  oldest  as  well  as  the  youngest.  The  basis  of  this  plan  is 
the  proposition  that  it  is  better  to  clean  and  care  for  the  teeth  of 
nine  children  who  have  one  decayed  tooth  apiece  than  it  is  to 
spend  the  same  time  caring  for  one  child  with  nine  decayed  teeth. 
While  this  policy  results  in  leaving  many  serious  cases  almost 
uncared  for,  it  secures  the  maximum  advantage  for  the  minimum 
expenditure  and  will  make  it  possible  to  cope  with  the  entire 
problem  within  a  few  years. 

OTHER  COUNTRIES 

Dental  inspection  is  well  under  way  in  Wales  and  notably 
good  work  has  been  done  in  Scotland,  especially  in  the  town  of 
Dunfermline.  Dental  clinics  have  been  established  for  school 
children  in  several  of  the  cities  of  Switzerland,  Austria,  and  France, 
and  the  latest  report  from  Russia  tells  of  the  establishment  of 
nine  dental  clinics  in  the  city  of  St.  Petersburg. 


DENTAL  INSPECTION  IN  THE  UNITED  STATES 

After  the  pioneer  work  carried  on  temporarily  in  Rochester, 
New  York,  a  quarter  of  a  century  ago,  the  city  again  became  a 
pioneer  by  establishing  the  first  American  school  dental  clinic 
in  the  modern  sense  of  the  term  in  1905.  This  was  made  possible 
by  the  public  spirited  enterprise  of  Mr.  Henry  Lomb,  who  person- 
ally gave  $600  and  was  instrumental  in  securing  an  equal  amount 
from  local  merchants  with  which  to  purchase  a  $1,200  equipment. 
Premises  for  the  clinic  were  supplied  by  the  Public  Health  Asso- 
ciation and  work  was  at  first  carried  on  two  afternoons  each  week. 
A  little  later  there  was  a  re-organization  which  resulted  in  the 

120 


Every  pupil  in  Rochester,  N.  Y.,  needing  dental  inspection  receives  it. 


Toothbrush  drill  in  New  York  City. 


DENTAL    INSPECTION 

employment  of  two  dentists,  one  of  whom  was  on  duty  each  week- 
day from  2  to  5  p.m.  These  men  were  paid  at  the  rate  of  $50 
a  month.  This  expense  was  met  by  Mr.  Lomb.  Since  that  time 
two  other  clinics  have  been  established  in  two  of  the  public 
schools. 

In  New  York  City  there  are  17  dental  clinics.  Fourteen 
of  these  are  connected  with  general  dispensaries  or  dental  colleges 
and  treat  both  adults  and  children ;  the  other  three  are  independent 
and  are  exclusively  for  school  children. 

In  1907  the  Children's  Aid  Society  of  New  York  opened  a 
clinic  for  the  treatment  of  children  enrolled  in  its  schools.  This 
clinic  was  so  successful  that  another  was  established  in  1909.  The 
society  meets  the  expense  of  equipment  and  maintenance,  and 
members  of  local  dental  societies  give  their  services. 

In  January,  1910,  through  the  generosity  of  Judge  Peter 
T.  Barlow  and  several  of  his  friends,  a  free  dental  clinic  was  opened 
to  care  for  New  York  City  school  children  whose  parents  are  too 
poor  to  pay  for  dental  treatment.  Two  dentists  are  employed  and 
are  on  duty  every  afternoon  from  Monday  to  Friday  inclusive, 
and  on  Saturday  mornings.  The  board  of  health  supplies  a  nurse 
to  assist  the  dentists  and  to  instruct  the  children  in  the  care  of 
the  teeth. 

In  the  year  1909,  the  work  was  begun  in  Cleveland,  Ohio, 
and  in  Reading,  Pennsylvania,  and  both  cities  have  been  leaders  in 
demonstrating  its  value  and  contributing  to  its  technique. 

From  these  early  beginnings  the  movement  for  dental 
inspection  spread  rapidly  over  the  United  States  until  in  1911 
some  198  cities  reported  that  such  inspection  was  being  carried 
on  in  their  local  schools.  This  does  not  mean,  however,  that  the 
work  has  been  in  every  case  of  the  type  under  consideration.  It 
frequently  means  only  that  the  local  medical  inspector  examines 
the  children's  teeth  and  advises  them  to  secure  dental  treatment. 
However,  dental  inspection  carried  on  by  dentists  was  being  con- 
ducted in  89  American  cities  at  the  close  of  the  year  191 1. 

The  number  of  cities  in  each  division  carrying  on  dental 
inspection  and  the  number  of  cities  where  this  work  is  done  by 
dentists  are  shown  in  the  following  table: 

121 


MEDICAL    INSPECTION    OF    SCHOOLS 


TABLE  32. — CITIES  OF  THE  UNITED  STATES  HAVING  DENTAL  INSPEC- 
TION   AND    CITIES    HAVING    DENTAL    INSPECTION    BY    DENTISTS, 
BY  GROUPS  OF  STATES.       II  I 


Division 

Cities  having  dental 
inspection 

Cities  having  dental 
inspection  by  dentists 

North  Atlantic       .... 
South  Atlantic        .... 
South  Central         .... 
North  Central        .... 
Western  

94 
15 

8 

59 

22 

38 
4 
39 

United  States         .... 

I98 

89 

ADMINISTRATION 

In  nearly  all  cases  dental  inspection  in  America  has  had  its 
inception  in  volunteer  work  of  the  local  dental  association.  This 
generally  results  in  an  arrangement  whereby  the  association 
carries  on  demonstration  work  in  the  public  schools.  When  the 
experimental  stage  is  past  the  dental  inspection  in  the  public 
schools  and  the  remedial  work  carried  on  through  clinics  are 
usually  administered  by  the  public  school  authorities  and  the 
dental  association,  acting  in  co-operation. 

A  good  example  of  this  sort  of  co-operation  is  found  in  Read- 
ing, Pennsylvania,  where  the  medical  inspectors  in  the  public  schools 
examine  the  children  and  select  those  needing  treatment.  The 
local  charity  organization  society  investigates  the  home  condi- 
tions of  candidates  for  gratuitous  treatment  and  the  local  dental 
society  supports  the  clinic  and  contributes  professional  services. 

In  New  York  City  the  clinics  exclusively  for  school  children 
are  supported  through  the  co-operation  of  the  children's  aid 
society,  the  dental  societies,  the  board  of  health,  and  private 
individuals  who  have  no  connection  with  the  public  schools. 
In  both  Milwaukee,  Wisconsin,  and  Ann  Arbor,  Michigan,  a 
woman  dental  inspector  is  employed  as  a  member  of  the  staff  of 
medical  inspectors  and  recommends  children  for  treatment,  send- 
ing them  either  to  clinics  or  to  private  dentists  as  their  finan- 
cial condition  makes  advisable. 

122 


DENTAL    INSPECTION 

The  situation  in  Philadelphia  is  of  particular  interest  because 
so  far  as  is  known  that  city  is  the  only  one  which  started  dental 
inspection  entirely  through  public  funds.  The  work  was  begun 
by  co-operative  endeavor  in  which  the  municipality  appropriated 
money  for  the  establishment  and  equipment  of  a  dental  clinic 
for  school  children  and  the  local  dental  societies  carried  on  volun- 
teer demonstration  work  for  nearly  a  year.  The  success  of  this 
experiment  led  to  the  appointment  of  eight  dentists  on  half  time 
at  a  salary  of  $700  per  year  each,  and  the  establishment  of  a  second 
clinic  in  one  of  the  public  schools. 

In  Valparaiso,  Indiana;  Muskegon,  Michigan;  Cincinnati, 
Ohio;  Elmira,  New  York;  and  in  many  other  localities  the  work  is 
carried  on  by  arrangements  between  the  public  schools  and  the 
individual  dentists  in  the  locality.  The  case  of  Muskegon  is 
particularly  interesting  because  of  the  nature  of  the  agreement 
entered  into  between  the  public  schools  and  the  dentists,  and  also 
because  of  the  marked  success  attained.  This  agreement  is  shown  by 
the  accompanying  reproduction  of  the  blank  used  for  the  purpose. 

AGREEMENT   BETWEEN    DENTISTS   AND   SCHOOLS,   MUSKEGON,   MICH. 


To  the  Honorable,  The  Board  of  Education 
of  the  Public  Schools  of  the  City  of 
Muskegon 

Gentlemen: 

I,  the  undersigned,  am  in  favor  of  a  Free  Dental  Clinic  and  agree 
to  give  at  least  one-half  day  of  my  time  every  three  months,  for  a  period  of 
one  year  (from  the  date  of  the  opening  of  the  office),  to  the  clinic  estab- 
lished by  the  Board  of  Education  in  the  Hackley  School. 

My  understanding  is  that  the  dates  of  assignment  shall  be  by  lot. 
I  will  take  charge  of  the  office  on  the  dates  assigned  to  me,  or  send  a  sub- 
stitute, provided  I  receive  notice  of  the  assignment  two  weeks  before  each 
date. 

Muskegon,  Mich., —        — 1911. 


Signature. 


In  Boston  plans  are  under  way  looking  toward  the  es- 
tablishment of  a  free  dental  infirmary  on  a  more  extensive  scale 
than  any  that  exists  elsewhere  in  the  world.  This  will  be  made 

123 


MEDICAL    INSPECTION    OF    SCHOOLS 

possible  through  the  gift  of  Mr.  Thomas  A.  Forsyth  who  under- 
took the  work  in  the  desire  to  establish  a  highly  practical  charity 
in  memory  of  his  brothers.  Mr.  Forsyth's  gift  amounts  to  about 
$500,000  and  it  is  hoped  that  this  sum  will  be  increased  by  other 
donations  to  a  total  of  something  like  $2,000,000.  The  object 
of  the  foundation  will  be  to  co-operate  with  the  school  authorities 
in  extending  popular  education  in  dental  hygiene  and  in  furnishing 
dental  services  free  to  every  child  in  the  city  from  early  childhood 
to  the  age  of  sixteen.  Already  a  charter  has  been  granted  by 
the  Massachusetts  legislature  and  land  purchased  for  the  erec- 
tion of  a  building.  The  plan  contemplates  the  most  modern  and 
complete  equipment  possible. 

LEGAL  PROVISIONS 

Up  to  the  present  time  New  Jersey  is  the  only  state  that  has 
passed  a  legal  enactment  specifically  providing  for  the  public 
support  of  free  dental  clinics.  This  act  was  passed  in  March, 
1911,  and  is  as  follows : 

Be  it  enacted  by  the  Senate  and  General  Assembly  of  the  State  of 
New  Jersey: 

i.  Section  one  of  an  act  of  the  Legislature  of  this  State,  entitled, 
"An  Act  to  authorize  cities  of  this  State  to  make  annual  appropriations 
to  incorporate  dental  associations  of  this  State  conducting  and  maintain- 
ing dental  clinics  in  such  cities  for  the  free  treatment  of  indigent  persons," 
approved  April  ninth,  one  thousand  nine  hundred  and  ten,  be  amended  so 
that  the  said  section  shall  read  as  follows: 

1.  Whenever  any  dental  association  regularly  incorporated  under 
the  laws  of  this  State  shall  maintain  and  conduct  in  any  city  of  this  State 
a  dental  clinic  or  clinics  where  indigent  persons  residents  of  such  city  may 
receive  treatment  and  relief  without  charge  or  fee  therefor,  it  shall  be  law- 
ful for  the  board  or  body  having  control  of  the  finances  of  such  city  to 
appropriate  and  pay  to  such  association,  each  year,  such  sum  or  sums, 
not  exceeding  in  all  the  sum  of  five  thousand  dollars,  as  it  shall  deem  advis- 
able, to  be  used  and  applied  by  such  association  only  for  the  support, 
maintenance  and  equipment  in  such  city  of  a  dental  clinic  or  clinics,  for 
the  free  treatment  of  indigent  persons,  residents  of  such  city  and  for  no 
other  purpose  whatsoever. 

2.  This  act  shall  take  effect  immediately. 
Approved  March  30,  1911. 

124 


DENTAL  INSPECTION 

COST  OF  SUPPLIES  AND  EQUIPMENT 

Experience  in  the  equipment  of  dental  clinics  shows  that  the 
cost  of  a  complete,  high  grade  equipment  with  one  chair  is  approxi- 
mately $700.  As  the  number  of  chairs  increases,  the  cost  per  chair 
becomes  somewhat  less  because  all  of  the  equipment  does  not  have 
to  be  duplicated  for  every  new  chair  installed.  The  common 
items  of  expense  are  about  as  follows: 

Chair $170 

Table 10 

Flush  spittoon  with  water  attachment        ....  60 

Electric  engine 140 

Electric  heater  and  sterilizer 25 

Excavators 18 

Chisels 25 

Appliances  for  use  with  engine 75 

Miscellaneous  hand  instruments 50 

Initial  supplies 127 

$700 

These  figures  are  taken  from  the  accounts  of  the  Philadelphia 
clinic.  They  agree  substantially  with  data  from  other  cities. 

In  New  York  City  it  has  been  found  that  the  expense  for 
establishing  a  clinic  is  about  $750,  and  the  annual  maintenance  costs 
about  $250,  not  including  payment  for  the  services  of  the  dentists. 
In  one  clinic  of  two  chairs,  where  equipment  and  supplies,  the 
expense  of  rent,  salaries  of  two  dentists  and  a  nurse,  etc.,  were  met 
from  clinic  funds,  the  total  expenses  for  one  year  were  $4,631.31. 
Of  this  sum  $1,129.61  was  expended  on  permanent  equipment; 
the  remaining  $3,501.70  represented  the  cost  of  maintenance. 

The  directors  of  the  Elmira  clinic  figure  that  with  an  annual 
appropriation  of  $400  they  can  meet  the  running  expenses  of  the 
clinic,  including  supplies,  laundry,  and  incidentals. 

In  Muskegon,  Michigan,  an  equipment  with  one  chair 
cost  $750  and  in  Rochester,  New  York,  one  with  two  chairs  cost 
$1200.  In  Reading,  Pennsylvania,  a  most  excellent  outfit  with 
one  chair  was  secured  for  about  $600,  but  because  of  donations 
and  specially  reduced  prices  this  represents  a  real  value  of  more 
nearly  $1000. 

PER  CAPITA  COST 

The  best  data  as  to  per  capita  cost  are  drawn  from  the 
European  experience.  In  Hamburg  it  is  found  that  the  average 

125 


MEDICAL   INSPECTION    OF    SCHOOLS 


cost  of  treatment  per  child  is  about  26  cents.  Of  this  amount 
14  cents  is  paid  out  of  the  municipal  grant  and  the  remaining  12 
cents  is  paid  by  the  parents,  or  in  necessitous  cases  by  the  Poor 
Law  Committee.  German  experience  in  general  shows  a  per  capita 
cost  for  children  treated  varying  from  20  cents  to  47  cents.  The  ex- 
perience of  1 2  municipal  districts  is  shown  in  the  accompanying  table. 

TABLE  33. — DENTAL  INSPECTION  OF  SCHOOL  CHILDREN   IN  TWELVE 
GERMAN   MUNICIPAL   DISTRICTS.      YEAR  ENDING   APRIL,   IQI  I 


ANNUAL  COST 

Number 

Num- 
ber of 

Initial 

OF 
MAINTENANCE 

Number 

nf  fhil 

Per 

Municipal  district 

of  school 

rooms 

capital 

OJ   C/Jll- 

dren 

capita 

children 

in 
clinic 

outlay 

Salaries 

Ma- 
terial 

treated 

cost 

Berlin  I  . 

230,000 

6 

$1,944 

$2,736 

$486 

12,000 

$0.27 

Berlin  II 

7 

2,586 

2,620 

13,132 

.20 

Charlottenburg 

24,000 

6 

3,353 

9,949 

•34 

Cologne  . 

69,293 

10 

3.475 

2,187 

Dortmund 

35,000 

7 

1,944 

2,430 

729 

Dinsburg 

34,000 

5 

1,166 

2,916 

1,215 

8^735 

•47 

Schoneberg 

12,696 

4 

875 

,944 

340 

8,311 

.27 

Stuttgart 

20,000 

4 

2,187 

,604 

6,778 

.24 

Darmstadt 

9.057 

6 

1,458 

,312 

486 

Colmar    . 

6,200 

3 

972 

,045 

170 

3,095 

•39 

Mulhausen 

19,500 

3 

,312 

267 

3,610 

•44 

Strassburg 

20,680 

10 

2,775 

7,094 

-39 

According  to  the  English  experience  one  dentist  working  five 
days  a  week  may  be  expected  to  care  for  the  teeth  of  a  school 
population  of  from  3,000  to  4,000  children.  In  the  county  of 
Somerset  an  allowance  of  12  cents  per  child  is  made  for  material. 

Reports  from  Rochester,  New  York,  show  that  for  1910  the 
per  capita  cost  for  dental  treatment  was  57  cents.  Of  this  sum 
1 1  cents  was  for  material  used.  In  1911  there  was  a  per  capita 
increase  of  12  cents.  This  increase  was  due  to  the  fact  that 
during  1910  most  of  the  material  had  been  given,  while  in  1911 
practically  all  of  it  was  purchased  from  the  clinic  funds. 

According  to  the  charter  of  the  Elmira  School  Dental 
Infirmary  no  charges  can  be  made  for  treatment. 

The  Newark,  New  Jersey,  clinic  treats  all  school  children 
free,  but  they  can  donate  any  sum  they  wish  toward  the  support 
of  the  clinic. 

126 


DENTAL    INSPECTION 

In  Lynn,  Massachusetts,  the  dental  dispensary  in  connec- 
tion with  a  Neighborhood  House  makes  a  flat  charge  of  15  cents 
for  cleaning,  10  cents  for  extractions,  and  25  cents  for  each  filling. 
In  Winchester,  Massachusetts,  nine  local  dentists  devote  half  a 
day  a  week  to  treating  poor  school  children  at  a  flat  rate  of  25 
cents  per  case. 

SALARIES 

In  Strassburg,  Germany,  the  dental  clinic  employs  one 
director  on  part  time,  two  assistants  on  whole  time,  and  two 
nurses  at  an  annual  expenditure  of  $6,000  to  $6,500.  In  England, 
as  has  been  mentioned,  the  dentists  in  the  county  of  Somerset  are 
paid  at  the  rate  of  $7.50  for  each  six-hour  day.  In  Philadelphia 
the  eight  dentists  employed  are  paid  $700  a  year  for  half-time 
services.  In  Rochester,  New  York,  dentists  working  from  two 
to  five  o'clock  each  afternoon  are  paid  at  the  rate  of  $50  per  month. 

The  staff  of  the  two  Newark,  New  Jersey,  clinics  consists 
of  one  chief  and  four  consulting  dental  surgeons,  who  give  their 
services;  four  dentists,  who  are  on  half-time  for  six  days  a  week, 
at  an  annual  salary  of  $500  each;  and  two  attendants  on  whole 
time  at  $520  each.  In  addition  to  this  force  several  local  dentists 
work  without  pay. 

Ann  Arbor,  Michigan,  has  a  woman  dental  inspector  who  in- 
spects the  children's  teeth  twice  a  year  at  an  annual  salary  of  $400. 

EDUCATION  IN  DENTAL  HYGIENE 

One  of  the  most  valuable  features  of  the  work  in  dental 
inspection  is  the  education  of  teachers,  children,  and  parents  in 
dental  hygiene.  Dentists  have  been  wide  awake  to  the  importance 
of  this  feature  and  are  carrying  on,  both  abroad  and  in  this  coun- 
try, an  active  campaign,  the  keynote  of  which  is  prevention  and 
conservation.  Work  is  carried  on  by  means  of  leaflets,  illustrated 
lectures,  magazine  and  newspaper  articles,  and  dental  exhibits. 
In  New  York  the  state  board  of  health  has  four  dentists  on  its 
staff  of  lecturers  and  these  men  give  illustrated  lectures  to  teachers 
and  parents  in  cities  and  towns  throughout  the  state.  The 
Virginia  state  board  of  health  in  March,  1911,  issued  for  general 
distribution  a  bulletin  on  Good  Teeth  and  Bad:  The  Essentials 
of  Oral  Hygiene. 

127 


MEDICAL    INSPECTION    OF    SCHOOLS 


In  Valparaiso,  Indiana,  in  1911,  local  dentists  made  careful 
examinations  of  school  children,  and  the  results  of  their  findings 
were  made  into  tables  and  diagrams  showing  existing  conditions. 
These  were  explained  by  one  of  the  dentists  at  a  teachers'  meeting 
and  the  need  for  instruction  on  the  care  of  the  teeth  was  discussed. 
The  result  was  the  awakening  of  interest  on  the  part  of  the  teachers 
and  the  beginning  of  class-room  instruction  in  dental  hygiene. 
This  was  followed  up  by  a  dental  exhibit  shown  in  every  school 
house  of  the  city.  Local  cartoonists  interested  in  the  movement 
contributed  drawings. 

In  1910,  through  the  activity  of  the  Rochester,  New  York, 
Dental  Association  a  lecturer  who  knew  how  to  interest  children 
was  secured.  For  two  weeks  he  gave  illustrated  talks  in  the 
different  school  rooms  on  the  teeth  and  their  care.  At  the  end 
of  the  second  week  a  mass  meeting  of  citizens  addressed  by  men  of 
national  prominence  was  held.  This  resulted  in  general  and 
active  support  of  the  movement. 

In  Philadelphia  every  child  receives  a  tooth  brush  and  box 
of  tooth  powder  when  the  work  on  its  teeth  is  completed.  Direc- 
tions for  brushing  the  teeth  and  the  formula  of  the  powder  are 
printed  on  the  label  of  the  box.  The  following  is  a  reproduction 
of  the  label: 

COMBINED    DIRECTIONS    AND    PRESCRIPTION     FOR    TOOTH     POWDER, 

PHILADELPHIA 


DIRECTIONS 

Turn  out  about  a  teaspoonful  of 
powder  into  the  palm  of  one  hand, 
touch  the  powder  with  the  wet  brush, 
and  brush,  (i)  up  and  down  the  in- 
side of  the  lower  front  teeth,  (2)  the 
right,  and  (3)  the  left  side  of  the  lower 
back  teeth,  (4)  inside  of  the  upper 

PHILADELPHIA 
Department  of  Public  Health  and 
Charities 
BUREAU  OF  HEALTH 
DENTAL  DISPENSARY 
Room  706,  City  Hall 

of  the  upper  back  teeth,  (7)  outsides 
of  all  teeth,  upper  and  lower,  brush- 
ing up  and  down. 
To  clean  each  of  these  seven  divi- 

TOOTH  POWDER 

FORMULA 

Precipitated  Chalk  95% 

in  the  powder  in  the  hand. 
Brush  the  teeth  at  night  and  rinse 
the  mouth  night  and  morning  with 
table  salt  dissolved  in  warm  water. 

CastileSoap.  3%    Oil  of  Birch..  i% 
Saccharin  .  .  .  Y&  %    Oil  of  Pepper- 
mint    H% 

Compliments  of  the  DENTAL  CORPS 

128 


1 


DENTAL    INSPECTION 

The  Children's  Aid  Society  of  New  York  City  sells  tooth 
brushes  for  three  cents  apiece.  A  leaflet  containing  directions 
for  the  care  and  use  of  the  teeth  is  distributed. 

This  leaflet  reads  as  follows : 

DIRECTIONS  FOR  THE  CARE  AND  USE  OF  THE 

TEETH 

A  clean  mouth  is  essential  to 
good  health 

Clean  teeth  do  not  decay 
****** 

Prepared  by  the 

SCHOOL  DENTAL  CLINIC  OF  THE 
CHILDREN'S  AID  SOCIETY 

For. free  distribution  among  the  patients 
of  the  School  Dental  Dispensaries 

WHAT  ARE  YOUR  TEETH  FOR? 

To  grind  the  food  into  fine  particles,  and  mix  it  with  the 

saliva. 
Food  which  is  not  thoroughly  chewed  causes  indigestion 

and  constipation. 

HOW  LONG  SHOULD  THE  TEETH  LAST? 

Throughout  life. 
HOW  DO  WE  LOSE  THEM? 

By  decay  and  loosening. 
WHAT  CAUSES  TEETH  TO  LOOSEN? 

Deposits  of  tartar  upon  the  teeth  in  contact  with  the  gums, 
uncleanliness,  and  lack  of  use  in  chewing  the  food. 

WHAT  CAUSES  TEETH  TO  DECAY? 

Particles  of  food  and  candy  sticking  to  them,  lack  of  exer- 
cise in  the  thorough  chewing  of  food,  irregular  teeth, 
also  a  poor  physical  condition. 

WHERE  DOES  THE  FOOD  LODGE? 

Between  the  teeth,  in  the  crevices  of  the  grinding  surfaces, 
and  along  the  margin  of  the  gums. 

CAN  DECAY  BE  PREVENTED? 

Yes,  to  a  large  extent. 
9  129 


MEDICAL   INSPECTION    OF    SCHOOLS 

HOW  CAN  DECAY  BE  PREVENTED? 

By  the  thorough  chewing  of  the  food,  by  keeping  the 
mouth  clean  through  the  careful  use  of  the  tooth  brush 
with  tooth  powder  or  paste,  and  waxed  silk,  also  by 
keeping  up  the  general  health.  Such  care  will  also  pre- 
vent the  teeth  from  loosening. 

HOW  OFTEN  SHOULD  THE  TEETH  BE  CLEANED? 
At  least  twice  each  day,  before  breakfast  and  at  bed  time. 
Better  after  each  meal.    Tooth  powder  or  paste  should 
be  used  morning  and  night. 

HOW  SHOULD  THE  TEETH  BE  BRUSHED? 

In  an  up  and  down  direction,  allowing  the  brush  to  come 
well  up  over  the  gums  in  both  jaws.  This  should  be 
done  on  the  outer  surface  of  all  the  teeth.  Then 
open  the  mouth  and  carefully  brush  the  grinding  sur- 
faces, special  care  being  given  to  those  in  the  back  part 
of  the  mouth.  Then  by  tilting  the  brush,  cleanse  the 
inner  surfaces  of  the  teeth  again  allowing  the  brush  to 
come  well  up  on  to  the  gums.  The  tongue  should  also 
be  extended  from  the  mouth  and  brushed. 

ARE  THE  GUMS  INJURED  BY  BRUSHING? 

No,  if  brushed  in  an  up  and  down  direction.  They  will  be 
strengthened  by  such  brushing  and  rendered  less  liable 
to  disease. 

HOW  OFTEN  SHOULD  THE  TEETH  BE  EXAMINED 
BY  A  DENTIST? 
At  least  twice  each  year. 

WHAT  IS  THE  PURPOSE  OF  THE  DENTAL  CLINIC 
OF  THE  CHILDREN'S  AID  SOCIETY? 
To  provide  free  dental  treatment  to  the  children  of  the 

school. 

To  teach  them  the  care  and  use  of  the  teeth. 
To  help  them  to  understand  that  a  clean  mouth  is  as 

important  as  a  clean  body. 

That  food  thoroughly  chewed  is  more  easily  digested. 
That  good  digestion  is  the  first  essential  to  health. 
That  well  cared  for  teeth  and  a  clean  mouth  help  prevent 

tuberculosis. 
That  cleanliness  and  fresh  air  are  the  best  safeguards 

against  disease. 

130 


DENTAL   INSPECTION 

Waltham,  Massachusetts,  distributes  a  leaflet  on  the  care  of 
the  teeth,  addressed  to  the  parents  of  the  school  children: 

THE  TEETH  AND  THEIR  CARE 

Waltham,  Mass. 
To  Parents: 

You  are  reminded  of  the  necessity  for  early  care  of 
children's  teeth.  With  such  care,  the  teeth  may  be  preserved 
throughout  life.  This  will  not  only  save  much  inconvenience 
and  discomfort  in  later  life,  but  it  may  enable  the  child  in  the 
meantime  to  live  a  more  vigorous  and  hence  a  more  successful 
life. 

The  condition  of  the  teeth  has  much  to  do  with  the  gen- 
eral health. 

The  following  cautions,  abbreviated  from  those  issued 
to  teachers  and  school  physicians  by  the  Massachusetts  board 
of  education,  are  commended  to  your  attention: 

Unclean  mouths  promote  the  growth  of  disease  germs, 
and  cavities  in  the  teeth  are  centers  of  infection. 

Irregularities  of  the  teeth,  especially  those  which  make 
it  impossible  to  close  the  teeth  properly,  thus  leading  to  faulty 
digestion  and  faulty  breathing,  should  receive  careful  treat- 
ment. 

The  first  permanent  molars  are  perhaps  the  most  impor- 
tant teeth  in  the  mouth.  They  come  at  about  the  sixth  year, 
immediately  following  the  temporary  teeth,  and  are  the  most 
frequently  neglected  because  they  are  often  mistaken  for 
temporary  teeth. 

It  should  be  known  that  decay  of  the  teeth  is  caused 
primarily  by  the  fermentation  of  starchy  foods  and  sugars, 
and  that  the  greatest  factor  in  preventing  disease  of  the  teeth 
is  the  removal  of  food  particles  by  frequent  brushing.  Chil- 
dren should  be  prevented  from  eating  crackers  and  candy 
between  meals,  and  when  possible  the  teeth  should  be  cleaned 
after  eating.  Inspection  of  the  teeth  by  a  dentist  should  be 
made  at  least  once  or  twice  a  year. 

Your  attention  is  also  called  to  the  prevalence  of  mala- 
dies of  the  nose  and  throat. 

The  health  of  a  child  and  his  ability  to  do  his  school  work 
may  be  seriously  impaired  by  the  presence  of  adenoid  growths. 
When  a  child  shows  obstruction  of  the  nose  by  mouth  breath- 


MEDICAL   INSPECTION    OF   SCHOOLS 

ing,  snoring,  continual  discharge,  or  recurrent  ear  trouble, 
adenoids  should  be  suspected. 

Enlarged  tonsils,  recurrent  tonsilitis,  and  enlargement 
of  the  glands  in  the  neck  also  constitute  a  serious  handicap 
to  the  child.     Either  condition  must  be  remedied  before  he 
can  have  a  fair  chance  in  the  world,  and  the  earlier  the  better. 
The  family  physician  should  be  consulted  and  the  child  given 
such  treatment  as  he  may  advise. 
Waltham,  Mass., 
January  i,  1908 

In  many  California  cities  the  school  authorities  distribute 
a  series  of  health  pamphlets  prepared  by  Dr.  Ernest  Bryant  Hoag.* 
In  this  series  belongs  the  following  on  The  Causes,  Results,  and 
Prevention  of  Poor  Teeth. 

HEALTH  PAMPHLET  NO.  3 

by 

Dr.  Ernest  Bryant  Hoag 
The  Effects  of  Decayed  Teeth 

It  has  been  shown  by  examination  of  school  children 
throughout  the  United  States  that  from  seven  to  eight  out  of 
every  ten  have  decayed  and  defective  teeth,  needing  the  care  of  a 
dentist. 

The  condition  of  the  teeth  has  a  very  important  bearing 
on  the  health  of  the  child.  By  early  attention  not  only  much 
inconvenience,  discomfort  and  greater  expense  in  later  life 
may  be  saved,  but  it  will  enable  the  child  in  the  meantime  to 
live  a  more  vigorous  life  and  be  more  healthy. 

Very  often  business  men  do  not  want  in  their  employ 
people  whose  breath  is  offensive,  whose  teeth  are  decayed, 
blackened  and  unsightly. 

It  is  the  best  of  economy  on  the  part  of  the  parent  to 
have  the  teeth  of  the  children  examined  once  or  twice  a  year 
by  a  dentist.  If  the  cavities  become  large  the  expense  of  filling 
and  the  pain  suffered  will  be  greater,  or  the  tooth  will  be  lost. 
It  is  frequently  thought  that  baby  teeth  may  be  neg- 
lected, that  the  cavities  are  of  no  importance.  This  is  wrong. 
Digestive  troubles  and  poor  nutrition  are  frequently  traced  to 
the  neglect. 

*  For  other  pamphlets  in  this  series,  see  pp.  80-82. 
132 


DENTAL    INSPECTION 

Baby  teeth  can  be  filled  with  cement  easily  and  with 
little  pain. 

Neglect  of  baby  teeth  is  often  the  cause  of  the  coming 
in  of  irregular  permanent  teeth. 

Irregular  teeth  are  unsightly.  The  irregularity  often 
causes  imperfect  closure  and  inability  to  chew  the  food. 

Poor  mastication  of  food  in  childhood  is  often  the  cause 
of  serious  stomach  disorders.  This  means  prolonged  suffering 
and  doctors'  bills. 

Food  which  is  not  thoroughly  chewed  causes  constipa- 
tion and  indigestion. 

Decay  of  teeth  can  be  prevented. 

An  unclean  mouth  is  an  excellent  place  for  the  growth 
of  disease  germs. 

It  is  a  fact  that  tuberculosis  often  gains  entrance  to  the 
glands  of  the  neck  and  so  to  the  lungs  through  decayed  places  in 
the  teeth. 

Abscesses  of  the  jaw  and  glands  of  the  neck  come  from 
decayed  teeth. 

Bad  conditions  of  nose,  throat  and  ears  are  made  worse 
by  decay  of  teeth. 

Causes  of  Decay 

Small  particles  of  food  lodging  along  the  gums,  in  cavi- 
ties and  between  the  teeth  ferment.  The  protecting  enamel 
is  dissolved  by  the  substances  formed  by  this  fermentation. 
Cavities  result.  The  gums  are  also  liable  to  become  dis- 
eased. 

The  loosening  of  teeth  and  disease  of  the  gums  is,  in 
nearly  all  cases,  caused  by  collections  of  tartar. 

Tartar  collects  on  the  teeth  of  every  person.  It  fre- 
quently collects  along  the  teeth  down  under  the  gums  where 
it  can  only  be  reached  by  the  dentist's  instrument. 

The  Armenians  are  noted  for  their  beautiful  and  perfect 
teeth.  The  children  are  taught  to  clean  their  teeth  after  any- 
thing being  taken  into  the  mouth,  even  an  apple. 

If  a  child  is  taught  to  use  a  tooth  brush  in  early  life  he 
will  be  apt  to  take  proper  care  of  the  teeth  throughout  life. 
It  is  very  important  to  establish  cleanly  habits. 

It  is  more  important  for  children  to  brush  the  teeth  than  to 
wash  the  face. 

133 


MEDICAL   INSPECTION    OF    SCHOOLS 

RECORD  FORMS  AND  BLANKS 

The  simplest  systems  of  record  keeping  used  in  connection 
with  dental  inspection  consist  merely  of  small  charts  showing  in 
outline  a  full  upper  and  lower  set  of  teeth.  By  marking  these 
pictured  teeth  the  medical  inspector  indicates  which  of  the  child's 
teeth  are  in  need  of  attention. 

In  a  fully  developed  system  of  dental  inspection  including 
dental  clinics  and  examinations  of  children  in  the  schools  by 
dentists,  work  is  facilitated  by  using  a  set  of  nine  or  ten  records 
each  serving  its  own  end.  Perhaps  the  most  satisfactory  record 
system  of  this  sort  is  that  in  use  in  connection  with  the  dental 
clinics  of  Philadelphia.  Because  these  records  are  so  well  adapted 
for  the  work  they  are  designed  to  do  it  seems  worth  while  to  present 
the  series  in  detail. 

The  individual  record  card,  the  face  and  reverse  of  which 
appear  on  pages  135  and  136,  measures  5x8  inches  and  is  designed 
to  record  the  salient  data  concerning  the  teeth  of  one  child. 

After  the  child  has  been  examined  and  a  condition  found 
which  requires  treatment,  a  notice,  reproduced  on  page  137,  is  sent 
to  the  parent  telling  him  what  has  been  discovered  and  advising 
that  the  child  be  treated  by  a  competent  dentist. 

If  the  notification  to  the  parent  brings  to  light  the  fact  that 
he  desires  to  have  his  child  receive  dental  attention  but  is  unable 
to  pay  the  cost,  the  dental  inspector  and  the  principal  jointly 
issue  a  certificate,  shown  on  page  138,  authorizing  the  child  to  be 
treated  at  the  dental  dispensary. 

When  the  child  visits  the  dispensary  he  is  given  a  small 
appointment  card — see  page  139 — measuring  2^  x  3^  inches,  on 
which  are  written  the  date  and  hour  of  his  appointment  and 
which  contains  spaces  where  the  dentist  indicates  the  dates  on 
which  he  worked.  One  end  served  by  this  card  is  to  insure  that 
the  same  dentist  shall  carry  the  case  through  to  a  conclusion. 
Directions  for  brushing  the  teeth  are  on  the  reverse  of  the  card. 
These  are  the  same  as  those  already  reproduced  on  page  128  as 
part  of  the  label  on  the  tooth  powder  box. 


134 


INDIVIDUAL  DENTAL  RECORD  CARD,  PHILADELPHIA  (Face) 


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Remarks: 

DENTAL   INSPECTION 
NOTICE  TO  PARENT,   PHILADELPHIA 


Form  9  D.  D. 


CITY  OF  PHILADELPHIA 
Department  of  Public  Health  and  Charities 

BUREAU  OF  HEALTH 


DIVISION  OF  SCHOOL  INSPECTION 

DENTAL  DISPENSARY 
ROOM  706,  CITY  HALL 

PHILADELPHIA, 191 

Mr.. 


Dear 

This  is  to  notify  you  that  your  child 

attending 

School, 

is  in  need  of  Dental  treatment. 

progress  in  school  is  retarded  by  impairment  of 

general  health,  resulting  from  decayed  teeth. 

For  the  best  interests  of  your  child  we  strongly  advise 
that teeth  be  treated  at  once  by  a  competent  dentist. 

For  further  information  call  at  the  school  and  consult 
the  Principal. 


..INSPECTOR 


PRINCIPAL 

PLEASE  BRING  THIS  NOTICE  WITH  YOU  TO  THE  SCHOOL 


137 


MEDICAL    INSPECTION    OF    SCHOOLS 
CERTIFICATE  FOR  FREE  TREATMENT,  PHILADELPHIA 

Form  6  D.  D. 

CITY  OF  PHILADELPHIA 
DEPARTMENT  OF  PUBLIC  HEALTH  AND  CHARITIES 

BUREAU  OF  HEALTH 


DIVISION  OF  SCHOOL  INSPECTION 

DENTAL  DISPENSARY 

ROOM  706.  CITY  HALL 

Philadelphia, 191 

THIS  IS  TO  CERTIFY  that 

age Residence 

School Section 

Grade is  in  need  of  dental  treatment  and  the  pa- 
rents are  unable  to  pay  for  the  same. 


INSPECTOR 


PRINCIPAL 


PRESENT  THIS  CERTIFICATE  AT  ROOM  706,  CITY  HALL.    Office  Houn: 
Monday  to   Friday,  9  A.  M.  to  4  P.  M.     Saturday.  9  A.  M.  to  12  Noon. 


138 


DENTAL    INSPECTION 
APPOINTMENT  CARD,  PHILADELPHIA 


CITY  OF  PHILADELPHIA 
Department  of  Public  Health  and  Charities 


BUREAU  OF  HEALTH 

DENTAL  DISPENSARY:  Room  706  City  Hall. 
Branch— Southwark  School,  9th  and  Mifflin  Sts. 


HAS  AN  APPOINTMENT  FOR 


Monday at 

Tuesday at.... 

Wednesday at.... 

Thursday at.... 

Friday at.... 

Saturday at.... 

BRING  THIS  CARD  WITH  YOU 
Discharged .for Months 

SHOW  THIS  CARD  TO  YOUR  TEACHER 


ATTEST 
WHEN  PRESENT 


DIRECTIONS    FOR    BRUSHING    THE 
TEETH 

Turn  out  about  a  teaspoonful  of 
precipitated  chalk  into  the  palm  of 
one  hand,  touch  the  chalk  with  the 
wet  brush,  and  brush,  (i)  up  and 
down  the  inside  of  the  lower  front 
teeth,  (2)  the  right,  and  (3)  the  left 
side  of  the  lower  back  teeth,  (4)  in- 
side of  the  upper  front  teeth,  (5) 
right,  and  (6)  left  side  of  the  upper 
back  teeth,  (7)  outsides  of  all  teeth, 
upper  and  lower,  brushing  up  and 
down. 

To  clean  each  of  these  seven  di- 
visions, first  wet  the  brush,  then  dip 
it  in  the  powder  in  the  hand. 

Brush  the  teeth  at  night  and  rinse 
the  mouth  night  and  morning  with  a 
teaspoonful  of  table  salt  dissolved  in 
a  tumbler  of  warm  water. 


After  the  pupil  has  been  treated  at  the  dispensary  an  in- 
dividual record  of  the  work  done  is  made  and  filed.  This  is  a 
card  measuring  5x8  inches  and  its  face  is  identical  with  that  of 
the  individual  record  card  already  reproduced.  On  the  reverse 
are  spaces  for  recording  the  date,  the  operation  performed,  and 
the  name  of  the  operator. 

The  school's  record  of  the  work  done  takes  the  form  of  a 
card  measuring  5x8  inches  and  is  kept  by  the  principal.  On 
this  card,  seen  on  the  following  page,  are  spaces  for  recording  the 
names  of  the  pupils  and  the  dental  inspector  together  with  the 
action  taken  by  the  parent,  private  dentist,  or  dispensary. 

The  record  of  the  work  done  by  the  individual  dental 
inspectors  takes  the  form  of  a  card  measuring  5x8  inches  having 
spaces  wherein  the  inspectors  record  each  week  the  work  done 
on  each  school  day.  This  card  is  reproduced  on  page  141. 


139 


MEDICAL   INSPECTION   OF   SCHOOLS 


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WEDNESDAY 

THURSDAY 

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TOTALS 

141 


MEDICAL   INSPECTION    OF   SCHOOLS 

For  administration  purposes  the  dental  clinic  keeps  detailed 
monthly  reports  which  are  summaries  of  the  individual  reports 
received  from  the  children  and  the  schools.  There  are  two  princi- 
pal record  forms  which  are  sheets  designed  for  use  in  loose  leaf 
binders.  The  first  of  these  has  spaces  for  recapitulating  the  work 
during  each  day  of  the  month.  The  column  headings  are: 
Day  of  Month  Canals  Pericementitis 

Daily  Number  of  Dressed  Alveolar  Abscess 

Patients  Filled  Gingivitis 

Fillings  Pulps  Stomatitis 

Amalgam  Pulpitis  Cleansing 

Gutta  Percha  Capped  Extractions 

Cement  Devitalized  Miscellaneous 

Copper  Cement  Extracted 

The  second  of  the  two  recapitulation  sheets  has  spaces 
for  recording  the  work  done  each  month  by  the  individual  inspec- 
tors. The  column  headings  across  the  top  of  the  sheet  are: 

Inspectors,  Schools  Assigned,  Visits  Made,  Pupils  Examined,  Treat- 
ment Recommended,  Parents  Notified,  Parents  Called  on  Principal, 
Treated  by  Private  Dentist,  Recommended  by  Dispensary,  Treated  at 
Dispensary,  Treatment  Secured,  Remarks. 

SUMMARY. — In  summarizing  the  situation  with  respect  to  the 
dental  inspection  of  school  children  the  most  salient  fact  is  that  the 
commonest  of  all  physical  defects  among  school  children  is  decayed 
teeth.  Cases  of  dental  defectiveness  are  frequently  greater  in 
number  than  are  all  other  sorts  of  physical  defects  combined. 
Moreover,  it  is  probably  true  that  there  is  no  single  ailment  of  school 
children  which  is  directly  or  indirectly  responsible  for  so  great 
an  amount  of  misery,  disease,  and  mental  and  physical  handicap. 

Within  the  past  decade  those  having  the  greatest  interest 
in  the  physical  welfare  of  children  have  awakened  to  the  existence 
of  these  conditions  and  vigorous  steps  have  been  taken  to  remedy 
them.  First  in  Germany,  next  in  England,  and  more  recently 
in  the  United  States  dental  inspection  has  been  inaugurated  and 
school  dental  clinics  established.  The  means  and  methods 
developed  have  so  conclusively  demonstrated  their  usefulness 
that  the  movement  is  everywhere  extending  rapidly  and  steadily. 


142 


CHAPTER  X 

CONTROLLING  AUTHORITIES 
IN  AMERICAN   MUNICIPALITIES 

UNDER  American  systems  of  municipal  government,  the 
question  as  to  whether  medical  inspection  of  schools  is  a 
proper  function  of  the  board  of  education  or  the  board  of 
health  is  bound  to  arise  as  soon  as  the  organization  of  such  a 
system  is  contemplated.  The  claims  of  both  are  certain  to  be 
warmly  argued. 

On  the  side  of  the  board  of  health  is  the  argument  that  the 
machinery  of  government  already  existing  for  the  conservation 
of  the  health  of  the  community  may  properly  be  extended  to 
include  new  activities,  and  that  another  branch  of  the  government 
should  not  duplicate  social  machinery  already  existing.  It  is 
further  argued  that  an  important  feature  of  the  medical  inspection 
of  schools  is  the  detection  and  segregation  of  cases  of  contagious 
disease.  This  is  a  protective  measure  relating  to  the  safety  of 
the  whole  community,  and  as  such  should  remain  a  function  of 
the  board  of  health. 

The  argument  for  keeping  the  work  in  the  hands  of  the  board 
of  education  is  that  the  whole  work,  to  be  effective,  must  be 
closely  related  to  school  work  and  school  records;  that  friction 
is  inevitably  produced  when  those  in  charge  are  in  the  employ  of 
an  outside  body,  neither  responsible  to  nor  perhaps  in  sympathy 
with  those  who  have  the  schools  in  charge.  This  results  in  a  loss 
of  efficiency. 

The  further  claim  is  made,  and  substantiated  by  referring 
to  records  in  many  cities,  that  the  exclusion  of  cases  of  contagious 
disease  is  after  all  a  comparatively  small  part  of  the  work  of  med- 
ical inspection.  Thus  in  Newark,  New  Jersey,  in  1909-10,  the 
total  exclusions  amounted  to  4,955  in  a  school  membership  of 

143 


MEDICAL   INSPECTION    OF   SCHOOLS 

57,742,  or  about  8  per  cent.  In  Cincinnati  and  Rochester  in  the 
same  year  the  exclusions  amounted  to  between  3  and  4  per  cent, 
in  Philadelphia  and  Spokane  to  4  per  cent  of  the  membership. 
In  the  state  of  Massachusetts  in  1907,  towns  and  cities  having  an 
average  attendance  of  342,000  reported  something  more  than 
1 5,000  exclusions  during  the  year.  Again  the  percentage  is  4.  It 
should  be  mentioned  that  in  many  cities  cases  of  pediculosis  form 
a  very  large  proportion  of  the  diseases  listed  as  communicable. 
In  New  York  City,  where  only  the  worst  cases  of  this  class  are 
excluded,  the  total  exclusions  in  1909-10  amounted  to  little  more 
than  i  per  cent  (8,884)  °f  a  total  membership  of  744, 148. 

These  facts  have  a  direct  and  important  bearing  on  the 
question  at  issue.  The  data  showing  that  the  proportion  of  cases 
requiring  exclusion  on  account  of  contagious  disease  does  not 
exceed  4  per  cent  of  the  school  membership  indicate  that  the  por- 
tion of  the  work  falling  within  the  purview  of  the  department  of 
health  is  specific  and  limited.  On  the  other  hand,  the  fact  that 
all  the  children  need  medical  and  sanitary  supervision  with  respect 
to  exercises,  suitable  seats  and  desks,  type,  paper,  suitable  hours 
of  study  and  recreation,  drinking  water,  physical  and  mental 
defects,  and  the  like,  indicates  that  the  portion  of  the  work  which 
legitimately  forms  a  function  of  the  educational  authorities  is 
general  in  nature  and  almost  unlimited  in  scope. 

By  far  the  most  important  evidence  bearing  on  the  problem 
is  that  drawn  from  the  experience  of  American  commonwealths 
and  municipalities.  Medical  inspection  laws,  or  regulations 
equivalent  to  laws,  are  now  in  force,  as  has  been  stated,  in  19  states 
and  the  District  of  Columbia.  It  is  most  significant  that  in  17 
of  these  20  cases  the  administration  of  the  provisions  is  placed  in 
the  hands  of  the  educational  authorities.  In  one  case  administra- 
tion may  be  through  either  the  department  of  health  or  the  depart- 
ment of  education,  and  in  only  two  cases  is  it  entirely  in  the  hands 
of  the  health  authorities. 

No  less  striking  is  the  situation  among  American  municipal 
systems.  In  the  early  days  of  medical  inspection  practically  all 
systems  were  administered  by  local  boards  of  health,  but  as 
experience  has  accumulated  the  tide  has  turned  until  at  the  present 
time  only  about  one-quarter  are  under  boards  of  health  and  in 

144 


CONTROLLING  AUTHORITIES 

the  remaining  three-quarters  the  board  of  education  is  the  con- 
trolling authority. 

In  the  investigation  conducted  in  1911,  as  has  been  stated, 
the  facts  concerning  medical  inspection  were  gathered  for  1,046 
school  systems  in  1,038  cities  and  towns.  Among  these,  443  had 
systems  of  medical  inspection.  The  following  table  shows  how 
these  systems  were  divided  between  the  two  forms  of  administra- 
tion. 


TABLE  34. — ADMINISTRATION  OF  SYSTEMS  OF  MEDICAL  INSPECTION 
IN  CITIES  OF  UNITED  STATES,  BY  GROUPS  OF  STATES.       19!  I 


Division 

Cities  having 
systems  of 
medical 
inspection 

Cities  having 
administra- 
tion by  board 
of  health 

Cities  having 
administra- 
tion by  board 
of  education 

North  Atlantic 
South  Atlantic 
South  Central 
North  Central 
Western   . 

236 
23 
35 
109 
40 

58 
7 

12 

21 

8 

•78 

16 

23 
88 
32 

United  States          

443 

1  06 

337 

A  good  idea  of  the  feeling  of  those  in  charge  of  the  work  in 
localities  where  the  question  as  to  administration  has  been  raised 
may  be  gained  from  reading  some  extracts,  mostly  taken  from 
official  reports  made  by  executive  officers. 

In  his  report  for  1907  (pages  142-3),  William  H.  Maxwell, 
city  superintendent  of  schools  of  New  York,  says: 

"  Dual  responsibility  in  the  school — that  of  the  board  of  education 
and  that  of  the  department  of  health — always  has  resulted  and  always 
will  result  in  confusion  and  inefficiency  in  the  work  effected.  It  is  owing 
to  this  dual  responsibility  that  the  large  annual  appropriation  made  by  the 
city  for  the  physical  examination  of  school  children  is  to  a  great  degree 
wasted.  Efficient  service  will  be  obtained  only  when  the  board  of  educa- 
tion is  made  solely  responsible  for  all  the  work  that  goes  on  in  the  schools. 

"The  physicians  employed  by  the  board  of  health  do  not  perform 
any  of  the  functions  which  it  is  highly  advisable  should  be  performed  by  a 
truly  educational  department  of  hygiene,  such  as  studying  hygienic  condi- 
10  145 


MEDICAL    INSPECTION    OF    SCHOOLS 

tions  in  the  schools  and  advising  teachers  regarding  the  pedagogical 
treatment  of  children  in  cases  of  fatigue  and  nervousness. 

"The  nurses  employed  by  the  department  of  health  have  done  good 
work  in  visiting  the  homes  of  sick  children,  in  giving  advice  and  assistance 
to  mothers,  and  in  looking  after  slight  ailments  in  the  school.  The  fact, 
however,  that  they  are  under  the  control  of  an  outside  organization  is  a 
constant  hindrance  to  their  work.  It  is  another  instance  of  the  evil 
effects  which  arise  from  dual  control  or  divided  responsibility.  I  risk 
nothing  in  saying  that  the  school  nurses  would  do  much  more  and  better 
work  if  they  were  made  responsible  to  the  educational  authorities." 

Dr.  Thomas  F.  Harrington,  of  the  department  of  hygiene, 
Boston,  says  *  in  speaking  of  the  system  of  medical  inspection  by 
physicians  in  the  employ  of  the  department  of  health: 

"The  greatest  criticism  against  this  system  of  inspection  is  that 
it  lacks  uniformity;  that  it  excludes  pupils,  and  does  not  provide  any 
means  of  'follow  up'  nor  any  guarantee  that  the  child  will  receive  medical 
care;  that  the  duties  of  the  inspector  as  an  agent  of  the  board  of  health 
bring  him  in  contact  with  much  contagion  in  the  homes;  and  finally,  that 
the  dual  duties  and  divided  responsibility  are  not  conducive  to  the  best 
in  the  health  and  efficiency  of  school  children." 

Speaking  of  the  work  of  the  school  nurses,  he  says :  * 

"  It  does  not  seem  possible  to  conceive  a  more  satisfactory  arrange- 
ment, nor  a  more  effective  piece  of  school  machinery,  than  nurses  under 
school  supervision.  With  a  corps  of  medical  inspectors  under  this  same 
supervision,  who  would  conduct  a  daily  clinic  in  their  respective  school 
districts,  there  are  no  problems  connected  with  the  health  and  efficiencv 
of  school  children  which  could  not  be  quietly,  rationally,  economically, 
and  effectually  solved.  Until  such  an  organization  is  perfected  in  part 
or  in  whole,  little  progress  can  result  from  the  efforts  to  promote  the  health 
and  efficiency  of  our  school  children." 

The  superintendent  of  schools  of  Boston  in  his  twenty- 
seventh  annual  report,  July,  1907  (page  39),  says  in  regard  to 
the  Massachusetts  law  making  medical  inspection  compulsory: 

"In  this  connection  it  should  be  stated  that  while  the  school  physi- 
cians were  concerned  solely  with  contagious  diseases,  they  were  properly 
to  be  controlled  by  the  board  of  health.     Under  the  new  law,  the  work 
*  School  Hygiene,  Sept.,  1908,  p.  21. 
146 


CONTROLLING  AUTHORITIES 

of  examining  into  any  defect  that  interferes  with  the  progress  of  the  chil- 
dren in  school  is  not  in  the  main  a  question  of  public  health.  It  is  rather 
an  educational  question  and  is  so  directly  allied  to  the  work  of  the  depart- 
ment of  physical  training  that  the  school  physician  should  be  appointed 
by  the  school  board  and  become  a  part  of  this  department.  The  highest 
efficiency  will  be  impossible  until  this  action  is  taken." 

The  superintendent  of  schools  of  Cleveland  says  in 
his  report  for  1907  (page  42),  after  making  an  able  plea  for  the 
establishment  in  the  schools  of  the  city  of  a  system  of  medical  su- 
pervision : 

"While  it  has  been  suggested  that  the  kind  of  service  here  treated 
should  be  performed  by  the  board  of  health,  it  is  the  belief  that  medical 
supervision  is  peculiarly  a  function  of  the  department  of  physical  training 
and  school  hygiene,  and  that  the  board  of  health's  relation  to  the  schools 
should  relate  to  the  matter  of  communicable  disease." 

In  his  report  for  1907  (page  119),  Dr.  Poland,  the  superin- 
tendent of  schools  of  Newark,  New  Jersey,  states  that  the  medical 
inspection  as  conducted  by  the  board  of  health  has  been  satisfac- 
tory, but  adds  that  the  only  objection  that  can  be  raised  against  it 
relates  to  the  executive  control  of  the  staff  of  medical  inspectors. 
He  says: 

"By  additions  to  the  staff,  the  number  of  medical  inspectors  now 
employed  in  the  schools  is  16.  The  direction  and  control  of  this  large 
number  requires  some  one  who  can  give  more  time  to  it  than  is  possible 
for  the  busy  and  overworked,  but  exceedingly  efficient,  health  officer.  It 
seems  hardly  fair  to  impose  upon  him  in  addition  to  his  other  duties  the 
duty  of  overseeing  daily  the  work  of  sixteen  medical  inspectors." 

Dr.  Fred  S.  Shepherd,  superintendent  of  schools  of  Asbury 
Park,  New  Jersey,  says  in  his  report  for  1907: 

"Again,  if  the  system  is  to  work  harmoniously,  the  medical  in- 
spector should  work  under  the  direction  of  the  superintendent  of  schools, 
as  do  the  teachers.  If  the  medical  inspector  should  regard  himself  as  not 
called  upon  to  accept  any  suggestions  whatsoever  from  the  school  officers 
of  administration,  such  as  superintendents  or  school  principals,  it  is  plain 
that  friction  might  arise.  In  this  connection  toe  should  not  overlook  the 
fact  that  medical  inspectors  are  human  and  have  a  few  of  the  faults  com- 

147 


MEDICAL    INSPECTION    OF    SCHOOLS 

mon  to  humanity.  It  is  possible  for  them,  as  it  is  for  teachers  and  others 
higher  in  authority,  to  slight  their  duties  or  to  perform  them  in  an  ineffi- 
cient and  unsatisfactory  manner.  School  boards  are  not  able  to  pass 
judgment  upon  these  inner  workings  of  the  system,  and  somebody  should 
have  the  responsibility  for  holding  even  medical  inspectors,  if  necessary, 
to  the  letter  if  not  to  the  spirit  of  their  obligations." 

It  is  to  be  noted  that  Superintendent  Shepherd  is  speaking, 
not  from  the  point  of  view  of  the  theorist,  but  from  that  of  one 
experienced  in  conducting  a  school  system  which  has  a  successful 
system  of  medical  inspection  conducted  by  physicians  appointed 
by  the  board  of  education.  In  describing  the  workings  of  this 
system  in  actual  practice,  Dr.  Shepherd  goes  on  to  say: 

"It  has  been  suggested  in  some  quarters  that  medical  inspection 
of  school  children  should  be  one  of  the  functions  of  the  local  board  of 
health,  in  order  to  prevent  clashing  of  authority.  As  boards  of  health 
are  organized  in  our  own  state,  however,  I  can  see  no  likelihood  of  such 
cross  purposes.  I  presume  it  does  devolve  upon  local  boards  of  health 
to  inspect  for  sanitary  purposes  all  public  buildings,  including  the  public 
schools.  This,  I  judge,  is  also,  or  should  be,  one  of  the  duties  of  the 
medical  inspector.  To  have  the  public  schools  inspected  intelligently 
by  two  such  departments  seems  to  me  a  good  thing.  What  one  might 
overlook,  the  other  might  see.  Aside  from  this  apparent  overlapping 
of  jurisdiction,  I  see  little  opportunity  for  any  clashing  of  interest.  On  the 
contrary,  it  is  possible  for  the  very  closest  relations  to  be  established 
between  boards  of  health  and  the  school  medical  authorities.  How  it 
might  be  in  other  cities  of  the  state,  I  am  not  aware;  but  in  the  city  of 
Asbury  Park  every  case  of  contagious  or  infectious  disease  is  reported 
immediately  by  the  board  of  health  to  the  school  authorities,  and  vice 
versa." 

That  the  fears  expressed  by  Dr.  Shepherd  are  not  groundless 
is  shown  by  experience  in  cities  where  the  dual  system  of  control 
is  in  practice. 

Such  an  example  comes  to  light  in  the  city  of  Lawrence, 
Massachusetts.  There  medical  inspection  is,  of  course,  con- 
ducted under  the  provisions  of  the  state  statute,  which  provides 
for  the  appointing  of  school  physicians  by  either  the  school  com- 
mittee or  the  board  of  health.  In  Lawrence  the  threatened  con- 
flict occurred  in  August,  1907,  when  the  board  of  health  appointed 

148 


Waiting  for  the  school  physician  in  Toledo,  Ohio. 


Throat  inspection  in  the  Orange,  N.  J.,  schools. 


CONTROLLING  AUTHORITIES 

five  physicians  to  inspect  both  public  and  private  schools.  By  an 
order  of  the  school  committee  the  principals  and  teachers  were 
forbidden  to  extend  official  recognition  to  any  but  Dr.  Bannon,  who 
had  been  appointed  by  the  school  committee  in  August,  1906,  for 
a  term  of  three  years.  This  state  of  affairs  continued  for  some 
time  and  the  schools  were  under  a  double  inspection,  with  much 
consequent  unavoidable  friction. 

One  of  the  strongest  arguments  in  favor  of  medical  inspec- 
tion under  the  authority  of  boards  of  education  undoubtedly  is 
that  efficiency  demands  that  there  shall  be  the  closest  co-operation 
between  the  medical  and  educational  authorities.  If  the  children 
are  to  be  benefited,  if  diligent  effort  is  to  be  made  to  correct  the 
defects  found,  if  the  physical  conditions  brought  to  view  are  to  be 
used  for  the  guidance  of  the  teacher  in  the  class  room,  then  certainly 
such  intimate  relationships  are  essential. 

It  has  been  claimed  that  where  inspection  is  conducted  under 
the  board  of  health  this  is  difficult  or  impossible.  Certainly  an 
examination  of  the  annual  reports  of  some  of  the  superintendents 
of  schools  in  cities  where  it  is  so  conducted  would  indicate  that  the 
educational  authorities  know  little  of  the  work  that  is  being  done, 
and  so  regard  it  as  of  slight  importance  as  a  guide  in  the  class  room. 
Examples  of  such  an  attitude  as  this  are  found  in  reports  of  the 
superintendents  of  schools  of  Haverhill  and  Springfield,  Massachu- 
setts, for  1907.  The  superintendent  of  schools  of  Haverhill  dis- 
poses in  his  report  of  the  subject  of  medical  inspection  with  the 
following  brief  remarks  (pages  32-33) : 

"The  school  physicians  have  continued  their  work  on  the  same  basis 
as  last  year,  under  appointment  from  the  board  of  health.  I  am  permitted 
to  make  the  following  summary  of  such  portions  of  their  work  as  admit 
of  classification.  A  large  proportion,  perhaps  the  largest  portion  of  their 
work,  is  not  such  as  can  be  shown  in  the  form  of  statistics." 

Then  follows  a  brief  list  of  the  diseases  noted  by  the  school 
physicians  and  of  the  statistics  concerning  vaccination.  No  details 
are  given,  nor  is  there  any  mention  made  even  of  the  number  of 
pupils  examined.  The  report  is  confined  to  some  10  lines.  Such 
comment  certainly  does  not  seem  to  indicate  intimate  knowledge 

149 


MEDICAL    INSPECTION    OF    SCHOOLS 

of  what  is  being  done,  or  a  close  relationship  between  the  work 
of  the  school  physicians  and  that  of  the  educational  authorities. 

A  similar  condition  seems  to  be  revealed  in  Springfield, 
where  the  sole  comment  of  the  school  board  on  the  work  of  the 
physicians  appointed  by  the  board  of  health  is  (page  17),  "So  far 
as  we  can  learn,  the  inspectors  are  fulfilling  their  requirements 
and  parents  generally  follow  the  advice  given/' 

In  Massachusetts,  medical  inspectors  are  appointed  in 
some  of  the  cities  by  the  boards  of  health  and  in  others  by  the 
school  committees.  After  watching  the  operation  of  the  two 
systems  for  more  than  a  year  under  the  state  law,  Secretary 
George  H.  Martin  of  the  state  board  of  education  writes:* 

"The  movement  now  in  progress,  which  has  reached  different 
stages  in  different  countries,  seems  to  be  shaping  itself  so  as  to  include  as 
necessary  features  the  following  elements: 

"(i)  Physicians.  A  sufficient  number  of  trained  physicians  to 
carry  on  the  necessary  examinations  and  exercise  the  needed  oversight  of 
all  the  children  in  the  public  and  private  schools,  these  physicians  to  act 
under  the  direction  of  the  local  educational  authority,  but  in  co-operation 
with  local  health  authorities.  In  the  larger  cities  the  physicians  should 
act  under  the  immediate  direction  of  a  chief  medical  officer,  who  should 
be  a  permanent  member  of  the  educational  staff." 

SUMMARY. — In  summing  up,  then,  we  may  conclude  as  a 
result  of  the  evidence  presented: 

1.  The  detection   of  contagious   diseases   in   the   schools, 
involving  daily  visits  by  physicians  and  the  power  of  the  law,  is 
in  the  nature  of  an  extension  of  the  powers  heretofore  exercised 
by  boards  of  health;   and  where  medical  inspection  is  to  include 
nothing  more  than  this  work,  systems  may  well  be  administered 
by  boards  of  health,  if  care  be  taken  to  establish  and  maintain 
sufficiently  close  and  friendly  relations  with  the  school  officials. 

2.  Those  activities  which  have  to  do  with  the  child's  phy- 
sical condition  and  the  hygiene  of  school  work — seating,  exercise, 
hours  of  home  study — that  is  to  say,  all  functions  of  the  medical 
inspection  of  schools  except  those  pertaining  to  contagious  diseases, 

*  Massachusetts  State  Board  of  Education,  yist  Annual  Report,  1906-07,  p.  123. 

150 


CONTROLLING  AUTHORITIES 

are,  in  the  nature  of  the  case,  an  integral  part  of  school  interests 
and  must  not  be  divorced  from  them.  Moreover,  the  records 
of  the  examination  of  school  children  for  physical  defects  likely 
to  interfere  with  proper  growth  and  education  must,  if  they  are  to 
serve  their  end,  follow  the  child  from  grade  to  grade  and  from 
school  to  school,  and  each  case  must  be  followed  up  constantly; 
that  is,  they  are  an  important  part  of  the  school  records  and 
must  be  so  made  and  administered. 
In  brief: 

(a)  Medical  inspection  for  the  detection  of  contagious  dis- 
eases may  well  be  a  function  of  the  board  of  health. 

(b)  Physical  examinations  for  the  detection  of  non-contagious 
defects  should  be  conducted  by  the  educational  authorities,  or 
at  least  with  their  full  co-operation,  because  they  are  made  for 
educational  purposes. 

(c)  The  records  of  physical  examinations  must  be  constantly 
and  intimately  connected  with  school  records  and  activities. 

(d)  They  do  not  need  to  be  connected  with  other  work  of  the 
board  of  health. 


CHAPTER  XI 
PHYSICAL  DEFECTS  AND  SCHOOL  PROGRESS 

THE  literature  of  the  newer  school  hygiene  contains  many 
references  to  the  close  relation   between  physical  defec- 
tiveness  and  school  retardation.    Unfortunately,  however, 
few  investigations  have  been  conducted  to  find  out  just  what 
relation  exists  between  progress  and  the  physical  condition  of  the 
pupil,  and  the  published  reports  of  such  investigations  as  have 
been  carried  on  are  meager  and  unsatisfactory. 

Six  American  studies  bearing  on  the  problem  are  sufficiently 
significant  to  warrant  review.  The  first  of  these  was  an  investiga- 
tion carried  on  by  Dr.  Walter  S.  Cornell  and  reported  in  the 
Psychological  Clinic  for  January,  1908.* 

DEFECTS  AMONG  "EXEMPT"  AND  "NON-EXEMPT"  CHILDREN 

In  Philadelphia,  where  Dr.  Cornell's  work  was  done,  the 
pupils  were  divided  into  so-called  "exempt"  children,  those  whose 
work  had  been  so  thoroughly  satisfactory  that  they  were  advanced 
to  higher  grades  without  examination,  and  "non-exempt,"  those 
whose  work  was  less  satisfactory.  Among  1,594  children  in  five 
schools  who  were  given  physical  examinations,  he  found  the  follow- 
ing: 

TABLE  35. — PER  CENT  OF  CHILDREN  EXAMINED  FOUND  DEFECTIVE, 
AMONG  907  "EXEMPT"  AND  687  "NON-EXEMPT"  CHILDREN, 

IN    PHILADELPHIA,  PENN. 


Exempt 
children 

Non-exempt 
children 

Number  examined    
Per  cent  defective    

907 

28.8 

687 
38.1 

*CornelJ,  Walter  S.,  M.D.:   The  Relation  of  Physical  to  Mental   Defect  in 
School  Children.     Psychological  Clinic,  Jan.  15,  1908,  pp.  231-234. 

152 


PHYSICAL  DEFECTS  AND  SCHOOL  PROGRESS 


Here  the  figures  show  that  the  percentage  of  defectives  is 
much  higher  among  the  non-exempt  than  among  the  exempt 
children.  We  are  given  no  details,  however,  as  to  defects  found 
and  so  no  data  indicating  which  particular  sort  or  sorts  of  defects 
caused  the  preponderance  on  the  side  of  the  non-exempt  pupils. 
Some  light,  however,  seems  to  be  thrown  on  this  problem  by  the 
results  of  an  investigation  conducted  in  1908  by  Dr.  S.  W.  New- 
mayer  in  the  schools  of  Philadelphia*  and  covering  the  examina- 
tions of  5,005  children,  of  whom  3,587  were  exempt  and  1,418  non- 
exempt.  Defects  were  found  among  them  as  follows: 

TABLE    36. — PHYSICAL    DEFECTS    AMONG    3,587    EXEMPT   AND    1,418 
NON-EXEMPT  CHILDREN,  IN  PHILADELPHIA,  PENN., 


Defect 

CASES  AMONG 

CASES  PER  100  CHILDREN 

AMONG 

Exempt 
children 

Non-exempt 
children 

Exempt 
children 

Non-exempt 
children 

Defective  vision 
Defective  hearing 
Defects  of  nose   . 
Defects  of  throat 
Orthopedic  defects 
Mentally  defective     . 
Skin  disease 
Miscellaneous     . 

371 
49 
54 
'37 
25 
6 
918 
214 

171 
29 

21 

53 
25 
80 
423 

128 

10 

2 

4 

i 

26 
6 

12 
2 
2 

4 

2 

5 
30 
9 

Total        .       .       . 

1.774 

930 

50 

66 

With  two  exceptions  the  defects  are  distributed  between 
the  two  classes  of  children  with  surprising  equality. 

The  brighter  pupils  seem  to  be  afflicted  in  about  the  same 
degree  as  their  duller  companions.  The  two  exceptions  occur  in 
the  cases  of  "mental  defects"  and  "skin  diseases,"  both  of  which 
are  more  frequent  among  the  duller  children.  That  the  former 
should  be  more  common  is  to  be  expected.  That  the  non-exempt 
children  should  be  found  to  suffer  more  commonly  from  skin 
diseases  is  probably  a  reflection  of  poorer  home  conditions  rather 
than  a  cause  of  their  lower  school  standings. 

*  Report  not  in  print. 
153 


MEDICAL    INSPECTION    OF    SCHOOLS 


DEFECTS  AMONG  NORMAL  AND  OVER-AGE  CHILDREN 
In  1906  Superintendent  James  E.  Bryan  of  Camden  con- 
ducted an  extensive  study*  of  the  relation  between  school  prog- 
ress and  physical  condition.  In  all,  10,130  children  were  given 
physical  examinations.  Of  these  children,  8, no  were  of  normal 
age  and  2,020  retarded.  The  results  of  the  vision  and  hearing 
tests  were  as  follows : 

TABLE  37. — DEFECTS  OF  VISION  AND  HEARING  AMONG  8,1  IO  NORMAL 
AND  2,O2O  RETARDED  CHILDREN  IN  CAMDEN,  N.  J.,  1906 


Children  of 
normal  age 

Retarded  chil- 
dren 

Number  examined    

8,no 

2,020 

Per  cent  having  defective  vision    .... 
Per  cent  having  defective  hearing 

27 
4 

29 
6 

From  these  data  one  would  hesitate  to  draw  conclusions 
as  to  any  relation  between  retardation  and  defective  vision  and 
would  feel  doubtful  with  regard  to  defective  hearing. 

Among  the  children  studied  1,852  had  failed  of  promotion. 
These  children  were  given  still  further  examinations.  Among 
them  1,279  were  of  normal  age  for  their  school  grade  and  573  were 
retarded.  The  results  of  the  examinations  were  as  follows: 

TABLE  38. — PHYSICAL  DEFECTS  AND  IRREGULAR  ATTENDANCE  AMONG 

1,279  NORMAL  AND   573   RETARDED  CHILDREN   WHO   FAILED  OF 

PROMOTION  IN  CAMDEN,  N.J.,  1906 


Children  of 

Retarded  chil- 

normal age 

dren 

Number  examined    

1,279 

573 

Per  cent  having  defective  vision    .... 

51 

40 

Per  cent  having  defective  hearing 

14 

1  1 

Per  cent  having  bad  health    

21 

21 

Per  cent  attending  irregularly       .... 

3° 

4° 

*Annual  Report  of  the  Board  of  Education  of  the   City  of  Camden,  New 
Jersey,  1907,  pp.  81-120. 

154 


PHYSICAL  DEFECTS  AND  SCHOOL  PROGRESS 


These  data  furnish  still  further  surprises.  The  children  of 
normal  age  actually  show  higher  percentages  of  defective  vision 
and  hearing  than  do  the  retarded  ones,  and  the  significant  feature 
disclosed  seems  to  be  that  irregular  attendance  rather  than 
physical  defects  is  the  important  factor  affecting  school  progress. 

DEFECTS  AMONG  PROMOTED  AND  NON-PROMOTED  CHILDREN 

In  his  report  for  1910  (page  37),  Superintendent  Verplanck 
of  South  Manchester,  Connecticut,  reports  results  of  physical  ex- 
aminations among  1,396  children,  of  whom  1,093  were  promoted 
at  the  end  of  the  year  and  303  failed  of  promotion.  The  find- 
ings are  as  follows: 

TABLE   39. — PHYSICAL   DEFECTS  AMONG   1, 093   CHILDREN    PROMOTED 

AND  303   CHILDREN  NOT   PROMOTED  IN   ELEMENTARY  SCHOOLS, 

IN  MANCHESTER,    CONNECTICUT,    I9IO 


Defect 

CASES  AMONG  CHILDREN 

CASES  PER  100  CHILDREN 
AMONG  THOSE 

Promoted 

Not  promoted 

Promoted 

Not  promoted 

Teeth        .... 
Throat      .... 
Adenoids 
Eyes         .... 
Other  defects 

272 
156 
162 
41 
23 

116 

39 
61 

25 
'4 
15 
4 

2 

38 
13 

20 

3 
3 

Total    .... 

654 

233 

60 

77 

These  figures  show  that  a  greater  percentage  of  the  non- 
promoted  than  of  the  promoted  pupils  had  adenoids  and  defective 
teeth.  In  the  case  of  the  other  defects  the  difference  in  the 
figures  is  so  slight  as  to  be  non-significant. 

DEFECTS  AMONG  RETARDED  CHILDREN 
In  his  report  for  1909-10  (page  28),  Superintendent  D.  C. 
Bliss  of  Elmira,  New  York,  reports  the  results  of  the  physical 
examinations  among  449  children  who  had  been  in  the  first  grade 
of  the  Elmira  schools  for  from  two  to  seven  years.  The  findings 
are  presented  in  Table  40. 

155 


MEDICAL    INSPECTION    OF    SCHOOLS 

TABLE    40. — PHYSICAL    DEFECTS    AMONG   449   RETARDED   CHILDREN, 

OF  WHOM  345   HAD  BEEN   IN  THE  FIRST  GRADE  TWO  YEARS,  86 

THREE    YEARS,    AND    l8    FOUR   OR   MORE   YEARS.       ELMIRA, 

NEW  YORK,   I9O9-IO 


Defect 

CASES  AMONG  CHILDREN 

CASES  PER  100  CHILDREN 
AMONG  THOSE 

2  years 
in  grade 

3  years 
in  grade 

4  or 
more 
years  in 
grade 

2  years 
in  grade 

)  years 
in  grade 

4  or 

more 
years  in 
grade 

Adenoids 
Hypertrophied  tonsils 
Anemia 
Enlarged  glands    . 
Defective  vision    . 
Defective  hearing 
Rachitis 

67 
141 

52 

77 
72 

17 
38 

18 
25 
15 
'9 

21 

3 
'9 

9 
9 

6 

5 
i 

4 

19 
4i 
15 

22 
21 

5 
I  I 

21 
29 

>7 
22 

25 

3 

22 

50 
50 
28 

33 
28 
6 

22 

Total  .... 

464                120 

39 

134 

139 

217 

A  study  of  the  figures  of  the  last  three  columns  shows  in 
general  an  increase  in  the  percentage  of  defects  found  as  we  pass 
from  the  pupils  who  had  been  in  the  first  grade  two  years  to  those 
who  had  been  there  three  years  and  to  the  most  retarded  group 
who  had  been  there  from  four  to  seven  years.  This  increase  of 
defects  with  progressive  retardation  is  particularly  evident  in  the 
case  of  the  pupils  who  had  adenoids  or  were  anemic. 


DEFECTS  AND  PROGRESS  IN  NEW  YORK 
In  a  study  of  retardation  in  the  New  York  public  schools, 
conducted  in  1908  by  the  Russell  Sage  Foundation,  a  careful 
tabulation  was  made  of  the  records  of  the  physical  examinations 
of  7,608  children  who  had  been  examined  by  school  physicians. 
When  these  records  were  tabulated  the  astonishing  condition  was 
brought  to  light  that  nearly  80  per  cent  of  the  children  who  were 
of  normal  age  for  their  grades  were  found  to  have  physical  defects, 
while  only  about  75  per  cent  of  the  retarded  children  were  defective. 
Another  noteworthy  point  was  that  the  percentage  of  defec- 
tive children  in  the  lower  grades  was  decidedly  greater  than  in  the 
upper  grades.  The  discovery  of  these  unlooked-for  results  led 

.56 


PHYSICAL  DEFECTS  AND  SCHOOL  PROGRESS 

to  further  study  of  the  figures.  The  data  were  retabulated  by 
ages,  and  the  findings  showed  a  marked  and  consistent  falling 
off  of  children  who  had  each  sort  of  defect  from  the  age  of  six 
up  to  the  age  of  fifteen.  Defective  vision  alone  increased  slowly 
but  steadily  with  advancing  age. 

Moreover,  these  decreases  were  not  due  to  the  falling  out 
or  leaving  school  of  children  suffering  from  defects.  This  might 
be  put  forward  as  an  explanation  if  we  had  to  do  with  children 
above  the  age  of  compulsory  attendance,  or  if  the  characteristic 
decrease  did  not  take  place  until  the  age  of  fourteen  or  fifteen; 
but  such  was  not  the  case.  The  children  were  from  six  to  fifteen 
years  of  age,  and  the  marked  decrease  began  with  the  seven, 
eight,  nine,  and  ten-year-old  children  and  continued  steadily. 

Were  further  data  not  available,  it  would  be  difficult  to 
explain  the  seeming  anomaly  that  retarded  children  have  fewer 
defects  than  do  children  of  normal  age;  but  the  data  showing  the 
decrease  of  physical  defects  with  increasing  age  are  illuminating. 
It  is  evident  that  here  age  is  the  important  factor.  The  impor- 
tance of  this  factor  in  all  investigations  into  the  influence  of  physical 
defects  on  school  progress  is  evident. 

Whether  the  term  "  retarded/'  referring  to  over-age  children, 
is  used  to  express  a  condition  or  an  explanation,  it  will  always 
follow  from  the  definition  itself  that  retarded  children  will  be 
older  than  their  fellow  pupils  in  the  same  grades.  In  all  cases  it 
will  always  be  true  that  the  "backward"  pupils  will  be  the  older 
pupils.  Now,  the  older  pupils  are  found  to  have  fewer  defects. 
This  is  true  whether  they  are  behind  their  grades  or  well  up  in 
their  studies.  Therefore,  it  is  not  surprising  that  we  find  80  per 
cent  of  all  children  of  normal  age  have  physical  defects  more  or  less 
serious,  while  but  75  per  cent  of  the  retarded  children  are  found  to 
be  defective.  This  does  not  mean  that  pupils  with  more  physical 
defects  are  brighter  mentally.  It  simply  means  that  those  who  are 
above  normal  age  are  older,  and  that  older  pupils  have  fewer  defects. 

In  order  to  ascertain  what  correlation  may  exist  between 
physical  defects  and  school  progress,  the  records  of  the  children 
were  retabulated,  using  age  instead  of  grade  as  a  basis,  so  that  the 
findings  should  not  be  vitiated  by  the  heterogeneous  age  composi- 
tion of  the  grades. 

157 


MEDICAL    INSPECTION    OF    SCHOOLS 


The  children  were  arbitrarily  divided  into  dull,  normal, 
and  bright  groups,  using  as  a  standard,  age  in  grade.  For  instance, 
it  was  considered  that  the  eleven-year-old  child  in  the  first  grade 
may  as  a  rule  be  safely  classed  as  dull,  whereas  the  ten-year-old 
child  in  the  sixth  or  seventh  grade  may  safely  be  considered  bright. 
Using  the  age-in-grade  criterion  as  a  basis,  the  records  of  the  ten, 
eleven,  twelve,  thirteen,  and  fourteen-year-old  children  were  re- 
tabulated  and  assigned  to  the  dull,  normal,  and  bright  classes. 
Results  are  shown  in  Table  4 1 . 

TABLE    41. — PER    CENT    OF    DULL,    NORMAL,   AND    BRIGHT    PUPILS 

SUFFERING     FROM     EACH     SORT    OF     DEFECT.      AGES     TEN     TO 

FOURTEEN,  INCLUSIVE.      ALL  GRADES.      NEW  YORK,   IQO8 


Defect 

Dull 

Normal 

Brigbt 

Enlarged  glands     

20 

13 

6 

24 

25 

2Q 

Defective  breathing       

15 

II 

9 

Defective  teeth       

42 

40 

34 

Hypertrophied  tonsils    

26 

'9 

12 

Adenoids         

15 

10 

6 

Here  we  have  figures  which  demonstrate  that  there  is  a  real 
relation  between  physical  defectiveness  and  school  progress. 
In  each  case,  save  that  of  vision,  a  larger  per  cent  of  the  dull 
pupils  is  found  to  be  defective  than  is  the  case  among  the  normal 
pupils,  and  these  again  are  more  defective  than  the  bright 
pupils.  The  fact  that  defective  vision  does  not  follow  this  same 
rule  is  somewhat  difficult  of  explanation.  There  can  be  no  ques- 
tion that  seriously  defective  vision  constitutes  a  real  handicap 
to  the  progress  of  the  child.  On  the  other  hand,  it  has  long  been 
a  matter  of  common  observation  that  the  brightest  and  most 
studious  pupils  are  often  afflicted  with  defective  eyesight.  It  may 
very  well  be  that  these  two  factors  somewhat  more  than  counter- 
balance each  other.  That  is  to  say,  while  defective  vision  is 
undoubtedly  a  real  handicap  and  is  the  cause  of  backwardness 
among  some  children,  there  are  found  in  the  same  classes  unusually 
bright  children  who  have  so  injured  their  eyesight  through  undue 
strain  and  use  that  they  too  have  very  defective  vision.  This 

158 


PHYSICAL  DEFECTS   AND   SCHOOL   PROGRESS 

explanation  cannot  be  put  forward  as  conclusive  for  there  are  no 
data  to  substantiate  it.  It  seems,  however,  a  reasonable  explana- 
tion and  one  which  coincides  with  the  known  facts  in  the  case. 


TABLE  42. — AVERAGE  NUMBER  OF  GRADES  COMPLETED  BY  PUPILS 
HAVING  NO  PHYSICAL  DEFECTS  COMPARED  WITH  NUMBER  COM- 
PLETED BY  THOSE  SUFFERING  FROM  DIFFERENT  DEFECTS.  CEN- 
TRAL TENDENCY  AMONG  3,304  CHILDREN,  AGES  TEN  TO  FOURTEEN 
YEARS,  IN  GRADES  ONE  TO  EIGHT.  NEW  YORK, 


Defect 

Average  number 
of  grades 
completed 

No  defects                             ...... 

A   QA 

Defective  vision             ........ 

A   QA 

Defective  teeth      ........... 

A   ()C 

A    C8 

A    KO 

4  24 

Enlarged  glands                    .                       .       . 

4  2O 

Scale  of  Grades 

2345 


No  defects — 4.94  grades 
Defective  vision — 4.94  grades 
Defective  teeth— 4.65  grades 
Defective  breathing — 4.58  grades 
Hypertrophied  tonsils — 4.50  grades 
Adenoids — 4.24  grades 
Enlarged  glands — 4.20  grades 


159 


MEDICAL    INSPECTION    OF    SCHOOLS 

The  results  shown  in  Table  41  (page  158)  indicate  that  there 
is  a  distinct  relation  between  progress  and  physical  defects. 
They  do  not,  however,  show  what  the  relation  is  in  terms  of  any 
given  units.  They  do  not  show  how  many  more  grades  are 
completed  by  the  non-defective  than  by  the  defective  child. 
In  order  to  arrive  at  such  a  measure  new  computations  were  made 
showing  the  average  number  of  grades  completed  by  the  ten-year- 
old  pupils,  by  the  eleven-year-old  pupils,  and  so  on  for  each  of  the 
other  ages.  The  central  tendency  of  all  of  these  sets  of  results  was 
then  computed.  The  findings  are  shown  in  Table  42  and  the  dia- 
gram which  follows. 

The  notable  feature  of  the  table  is  the  fact  that  in  every  case, 
except  that  of  defective  vision,  the  children  suffering  from  each 
sort  of  physical  defect  made  less  progress  in  their  school  work 
than  did  those  not  so  handicapped.  The  seriousness  of  these 
handicaps  in  terms  of  percentages  is  shown  in  Table  43. 

TABLE  43. — EXTENT  TO  WHICH   CHILDREN    SUFFERING   FROM   EACH 

SORT  OF  PHYSICAL  DEFECT  SHOW  SLOWER  PROGRESS  THAN  DO 

CHILDREN    WITH   NO   DEFECTS.      NEW   YORK,   1 908 


Defect 

Per  cent  of  loss 
in  progress 

Defective  vision                     ......... 

. 

Defective  teeth              

6 

Defective  breathing       
Hypertrophied  tonsils    
Adenoids         ............ 

7 

9 
14 

Enlarged  glands     

15 

0 

In  this  table  the  average  loss  of  9  per  cent  which  appears 
in  the  last  line  is  not  the  numerical  average  of  the  percentages 
of  loss  corresponding  to  the  different  sorts  of  defects,  but  the 
general  loss  of  progress  discovered  among  all  the  children  having 
physical  defects.  In  other  words,  the  children  suffering  from 
physical  defects  made  on  the  whole  9  per  cent  less  progress  than 
did  those  having  no  physical  defects. 

160 


PHYSICAL  DEFECTS  AND  SCHOOL  PROGRESS 

In  order  to  show  more  definitely  in  terms  of  school  prog- 
ress just  what  these  handicaps  mean  we  may  apply  them  to  the 
cases  of  hypothetical  non-defective  and  defective  children.  If 
we  assume  that  the  average  child  without  physical  defects  of  any 
kind  will  complete  the  eight  grades  in  just  eight  years,  how  long 
will  it  take  defective  children  to  complete  eight  grades?  The 
answer  to  this  question  may  be  found  in  Table  44  and  the  accom- 
panying diagram. 


TABLE  44. — NUMBER  OF  YEARS   REQUIRED  BY  DEFECTIVE  AND  NON- 
DEFECTIVE  CHILDREN  TO  COMPLETE  THE  EIGHT  GRADES. 
NEW  YORK, 


Deject 

Years  required 
to  complete 
eight  grades 

No  defects       

So 

Defective  vision     ......... 

So 

Defective  teeth      

8  <; 

Defective  breathing       

86 

Hypertrophied  tonsils  

87 

Adenoids         

91 

Enlarged  glands     

Q  2 

Scale  of  Years 

34       567       89 


No  defects  —  8  years 

1       1       1       I      1       1       1       1 

Defective  vision  —  8  years 

1       1       1       1      1       1       1       1 

Defective  teeth  —  8.5  years 

1       1       1       I      1       1       1       1    1 

Defective  breathing  —  8.6  years 

1       1       1        1      1       1       1       1    1 

Hypertrophied  tonsils  —  8.7  years  £ 

1       1      1        1      1       1       1       1      1 

Adenoids  —  9.1  years 

1       1       1       1      1       1       1       1       It 

Enlarged  glands  —  9.2  years 

I       1      I        1      1       1       1       1        II 

ii 

161 

v 


MEDICAL    INSPECTION    OF    SCHOOLS 

If  these  figures  are  substantially  significant  for  all  New  York 
City  school  children,  their  educational  and  economic  import  is 
great.  According  to  the  data,  the  child  with  seriously  defective 
teeth  requires  half  a  year  more  than  a  non-defective  child  to  com- 
plete the  eight  grades.  About  one-half  of  the  children  have 
seriously  defective  teeth.  The  handicap  imposed  by  defective 
breathing  means  six-tenths  of  a  year.  About  one  child  in  seven 
has  defective  breathing.  The  child  with  hypertrophied  tonsils 
takes  about  seven-tenths  of  a  year  more  than  he  should.  About 
one  child  in  every  four  has  hypertrophied  tonsils.  The  extra 
time  required  by  the  child  with  adenoids  is  about  one  and  one- 
tenth  years.  About  one  child  in  eight  has  adenoids.  The  pupil 
with  enlarged  glands  requires  one  and  two-tenths  years  extra. 
Nearly  half  of  the  children  have  enlarged  glands. 

The  sums  of -money-spent  annually  by  New  York  City  for 
public  education  reach  high  into  the  millions.  It  would  be  a 
simple  matter  to  compute  how  many  dollars  are  wasted  each  year 
in  the  futile  attempt  to  impart  instruction  to  pupils  whose  mental 
faculties  are  dulled  through  remediable  physical  defects.  Roughly 
speaking,  about  60  per  cent  of  all  the  children  suffer  from  such 
defects.  If,  then,  we  should  show  that  the  instruction  given 
these  children  suffers  a  loss  in  effectiveness  of  nearly  10  per  cent 
because  of  remediable  physical  defects,  it  is  evident  that  the  direct 
financial  bearing  of  the  problem  is  of  great  significance. 

Such  a  computation,  while  it  would  undoubtedly  prove 
interesting,  is  perhaps  better  left  unmade  because  we  do  not 
know  that  the  data  discussed  are  either  truly  reliable  or  generally 
representative.  They  are  based  on  a  comparatively  small  number 
of  cases  in  one  city,  in  one  year,  and  could  similar  data  be  se- 
cured for  longer  periods  of  time  and  in  more  localities  it  is 
not  only  possible  but  probable  that  they  would  show  different 
results. 

The  examination  is  important  because  it  establishes  the 
principle  that,  except  in  the  case  of  vision,  older  children  have 
fewer  defects.  It  shows  that  when  children  who  are  badly 
retarded  are  compared  with  normal  and  very  bright  children  in 
the  same  age  groups,  the  children  rated  as  "dull"  are  found  to 
have  higher  percentages  of  each  sort  of  defect  than  the  normal 

162 


PHYSICAL  DEFECTS  AND  SCHOOL  PROGRESS 

and  bright  children.  In  this  generalization  defective  vision  must 
be  excepted. 

Moreover,  the  investigation  gives  us  quantitative  measures 
of  the  retarding  forces  of  the  different  kinds  of  defects.  I  n  general, 
children  suffering  from  physical  defects  are  found  to  make  about 
9  per  cent  less  progress  than  children  having  no  physical  defects. 
The  figures  do  not  really  show  the  retarding  influence  of  each  sort 
of  defect  separately  for  the  reason  that  the  same  child  is  often 
suffering  from  several  sorts  of  defects. 

Because  of  the  reasons  that  have  been  mentioned,  the 
figures  may  be  accepted  as  having  distinct  value  in  revealing 
general  tendencies,  but  must  not  be  interpreted  as  showing  with 
precision  the  relative  retarding  force  of  each  separate  sort  of  defect, 
or  even  of  physical  defectiveness  in  general. 

Before  the  attempt  to  draw  detailed  and  final  conclusions 
on  this  subject  is  made,  a  series  of  similar  investigations  covering 
large  numbers  of  children  in  different  cities  should  be  conducted, 
and  the  results  carefully  analyzed  and  compared.  Until  some 
such  program  has  been  carried  out,  dogmatic  statements  making 
general  application  of  partial  results  should  be  avoided,  and  the 
tentative  character  of  all  conclusions  thus  far  formulated,  clearly 
recognized. 


163 


164 


CHAPTER  XII 
LEGAL  PROVISIONS 

TH  E  first  state  law  concerning  the  medical  inspection  of  school 
children  appears  to  have  been  passed  by  Connecticut  in 
1899.  It  did  not  provide  for  the  complete  sort  of  inspec- 
tion now  carried  on  in  many  cities  and  states,  but  only  for  the  test- 
ing of  eyesight  by  teachers  every  three  years.  Complete  medical 
inspection,  with  examinations  for  the  detection  of  physical  defects, 
was  first  provided  for  by  state  enactment  in  the  permissive  law 
of  New  Jersey  passed  in  1903.  This  was  followed  by  the  manda- 
tory law  of  Massachusetts,  in  1906,  which  has  been  several  times 
amended  and  has  served  as  the  basis  for  a  majority  of  the  bills 
which  have  since  been  presented  in  other  state  legislatures. 

By  the  beginning  of  the  year  1912,  as  has  been  stated,  seven 
states  had  mandatory  laws,  10  permissive  ones,  and  in  two  states 
(Louisiana  and  Minnesota)  and  the  District  of  Columbia  medical 
inspection  was  carried  on  under  regulations  promulgated  by  the 
boards  of  health  and  having  the  force  of  law.  The  accompanying 
map  shows  graphically  which  states  have  mandatory  laws,  which 
permissive  ones,  and  in  which  there  are  no  laws  at  all. 

The  past  five  years  have  furnished  a  large  body  of  experience 
gained  under  varying  conditions  in  widely  separated  localities. 
The  lessons  of  this  experience  can  be  read  in  the  substantial 
agreement  of  a  majority  of  the  laws  in  several  salient  features. 
This  agreement  is  graphically  shown  by  the  tabular  presentation  of 
the  principal  features  of  the  laws  and  regulations  on  page  166. 

On  four  points  there  is  substantial  agreement.  The  first 
is  that  the  administration  of  the  provisions  of  the  law  is  placed  in 
the  hands  of  the  school  authorities.  The  second,  third,  and 
fourth  are  respectively  the  placing  of  inspection  for  contagious 
diseases,  physical  examination,  and  inspection  of  teachers,  jani- 
tors, and  buildings  in  the  hands  of  school  physicians.  In  seven 
cases  provision  is  made  for  vision  and  hearing  tests  by  teachers. 


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LEGAL  PROVISIONS 

A  clear  idea  of  the  principal  provisions  of  the  different  laws 
may  be  gained  from  the  following  abstract: 

Abstract  of  Laws  and  Regulations  Covering  Medical  Inspection 

1.  CALIFORNIA 

Adopted  1909.     Permissive.     Applies  where  adopted 

Administered  by  school  authorities 

Provides  for  health   and   development   supervision  of 

teachers  and  pupils 
Inspectors  may  be  either  physicians  or  educators 

2.  COLORADO 

Adopted  1909.    Mandatory.   Applies  to  all  public  schools 

Administered  by  school  authorities 

Teachers  or  principals  test  sight,  hearing  and  breath- 
ing of  all  pupils  annually 

School  authorities  report  to  parents  mental,  moral  or 
physical  defectiveness  discovered 

Enforcement  by  State  Bureau  of  Child  and  Animal  Pro- 
tection 

3.  CONNECTICUT 

Adopted  1907.     Permissive.    Applies  where  adopted 
Administered  by  school  authorities 
Physicians  inspect  children  for  contagious  diseases 
Physicians  may  examine  teachers,  janitors  and  school 

premises 

Physicians  conduct  sight,  hearing  and  physical  examina- 
tions annually 
Defects  reported  to  parents 
School  authorities  may  appoint  school  nurses 

4.  DISTRICT  OF  COLUMBIA 

Regulations  of  health  officer  and  board  of  education 
Adopted  in  present  form  in  1907.     Mandatory.     Ap- 
plies to  all  public  schools 
Administered  by  health  authorities 
Physicians  examine  for  contagious  diseases 
Physicians  examine  sanitary  conditions  of  buildings 
Physicians  may  examine  teachers  and  janitors 

5.  INDIANA 

Adopted  1 91 1.     Permissive.     Applies  where  adopted 

Administered  by  school  authorities 

Physicians  inspect  children  for  contagious  diseases 

.67 


MEDICAL    INSPECTION    OF    SCHOOLS 

Teachers  may  test  sight  and  hearing  annually 

Physicians  conduct  physical  examinations 

Defects  reported  to  parents 

Not  more  than  2,000  children  for  one  physician 

Compensation  of  physician  not  less  than  $5.00  for  each 

school  month 

Physicians  may  examine  teachers,  janitors  and  buildings 
If  parents  are  too  poor  to  provide  necessary  medical 

treatment  it  shall  be  paid  for  from  public  funds 
Penalty  of  $5.00  to  $50.00  for  violation  of  provisions  of 

act 

6.  LOUISIANA 

Adopted  1911.  Regulations  of  sanitary  code  of  state 
board  of  health  having  force  of  law.  Mandatory. 
Applies  to  all  public  schools 

Administered  by  school  authorities 

Principal  of  each  school  makes  monthly  report  on  phy- 
sical condition  of  children  and  sanitary  condition  of 
buildings  on  blanks  furnished  by  state  board  of  health 

Principals  and  teachers  exclude  children  suffering  from 
contagious  disease 

7.  MAINE 

Adopted  1909.     Permissive.     Applies  to  cities  and  towns 

of  less  than  40,000 
Administered  by  school  authorities 
Not  more  than  1,000  pupils  to  a  physician 
Physicians  inspect  children  for  contagious  diseases 
Physicians  may  examine  teachers,  janitors  and  buildings 
Tests  of  sight   and   hearing  annually  by  teachers  or 

physicians 

Physical  examination  annually  by  physicians 
Defects  reported  to  parents 

8.  MASSACHUSETTS 

Adopted   1906;    amended   1910.     Mandatory.     Applies 

to  all  public  schools 

Administered  by  school  or  health  authorities 
Physicians  inspect  children  for  contagious  diseases 
Physicians  may  examine  teachers,  janitors  and  buildings 
Tests  of  sight  and  hearing  made  by  teachers  annually 
Physicians    make    physical    examinations    of    children 

annually 

1 68 


LEGAL  PROVISIONS 

Defects  reported  to  parents 

Normal   schools   train   students   in   testing   sight   and 

hearing 
Physicians  conduct  examinations  of  minors  applying  for 

age  and  schooling  certificates 
9.  MINNESOTA 

Regulations  of  board  of  health  having  force  of  law 
Adopted     1910.     Mandatory.     Applies    to    all    public 

schools 

Administered  by  health  authorities 
Physicians  examine  for  contagious  diseases 
Physicians  may  inspect  teachers,  janitors,  and  buildings 
Physicians  conduct  physical  examinations  annually 
Defects  reported  to  parents 
Teachers  test  sight  and  hearing  annually 
Normal  schools  train  pupils  in  testing  sight  and  hearing 

10.  NEW  JERSEY 

Adopted     1909.     Mandatory.     Applies    to    all    public 

schools 

Administered  by  school  authorities 
Physicians  examine  for  contagious  diseases 
Physicians   conduct    physical    examinations,    including 

sight  and  hearing  tests 
Defects  reported  to  parents 
Physicians  deliver  hygiene  lectures  to  teachers 
Parents  and  guardians  may  be  proceeded  against  as  dis- 
orderly persons  for  failure  to  remove  any  pathological 
condition  which  may  cause  a  child's  exclusion  from 
school 

1 1.  NEW  YORK 

Adopted  1910.     Permissive 

Authorizes  school  authorities  to  expend  school  funds  for 
the  support  of  medical  inspection 

12.  NORTH  DAKOTA 

Adopted  191 1.     Permissive.    Applies  where  adopted 
Administered  by  school  authorities 
Physicians  conduct  physical  examinations  annually 
Defects  reported  to  parents 

Co-operates  with  board  of  health  to  curb  contagious 
disease  and  to  secure  treatment  for  indigent  children 


169 


MEDICAL  INSPECTION  OF  SCHOOLS 

13.  OHIO 

Adopted  1910.     Permissive.     Applies  to  cities 
Administered  by  school  authorities,  but  powers  may  be 

delegated  to  health  authorities 
Physicians  inspect  children  and  schools 
School  nurses  may  be  employed 

14.  PENNSYLVANIA 

Adopted  1911.  Mandatory  in  districts  of  first  and 
second  class.  Permissive  in  districts  of  third  and 
fourth  class.  Districts  of  first  class  are  those  of  more 
than  500,000  population,  second  class  from  30,000  to 
500,000,  third  class  5,000  to  30,000  and  fourth  class 
less  than  5,000 

Administered  by  school  authorities 

Physicians  conduct  complete  physical  examinations  of 
children  annually 

Physicians  make  sanitary  inspection  of  school  premises 
annually 

In  districts  of  fourth  class  medical  inspectors  are  ap- 
pointed by  state  commissioner  of  health 

Provision  for  employment  of  graduate  nurses 

15.  RHODE  ISLAND 

Adopted  1911.  Mandatory  with  permissive  clause 
providing  for  employment  of  physicians 

Administered  by  school  authorities 

Physicians,  where  employed,  make  annual  examination 
of  pupils,  teachers,  and  janitors  in  public  and  private 
schools,  and  inspect  buildings  and  surroundings 

Annual  vision  and  hearing  tests  by  physicians  or  teachers 

Defects  reported  to  parents 

1 6.  UTAH 

Adopted     1911.     Mandatory.     Applies    to    all    public 

schools 

Administered  by  school  authorities 
Teachers  or  physicians  examine  all  children  annually  for 

defects  of  sight  or  hearing,  defective  teeth  or  mouth 

breathing 
Defects  reported  to  parents 

17.  VERMONT 

Adopted  1910.     Permissive.     Applies  where  adopted 
Administered  by  school  authorities 

170 


LEGAL  PROVISIONS 

Physicians  inspect  pupils  as  provided  by  rules  of  state 

board  of  health 
On  request,  physicians  examine  pupils  of  private  schools 

18.  VIRGINIA 

Adopted  1910.     Permissive.    Applies  where  adopted 
Administered  by  school  authorities 
Authorizes  school  boards  to  support  systems  of  medical 
inspection 

19.  WASHINGTON 

Adopted  1 909.    Permissive.    Applies  to  cities  of  first  class 

Administered  by  school  authorities 

Authorizes  school  boards  to  appoint  medical  inspectors 

who  shall  report  monthly  on  health  conditions  in 

each  school 

20.  WEST  VIRGINIA 

Adopted  191 1.     Mandatory  in  cities,  permissive  in  coun- 
try districts 

Administered  by  school  authorities 
Physicians  inspect  children  for  contagious  diseases 
Physicians  conduct  physical  examinations  annually 
Physicians,  on  request  of   board,   report  on   lighting, 

ventilation,  etc. 
School  nurses  may  be  employed 


PROVISIONS  NEW  LAWS  SHOULD   INCLUDE 

A  comparative  study  of  the  provisions  of  the  different  laws 
shows  that  with  the  added  experience  gained  through  knowledge 
of  how  the  older  measures  have  met  the  test  of  time,  school 
physicians  and  educators  have  incorporated  in  some  of  the  more 
recent  measures  features  which  are  genuine  improvements,  and 
which  should  be  provided  for  in  bills  for  new  medical  inspection 
acts  and  for  amendments  of  the  old  ones.  The  following  are  the 
features  which  it  would  seem  ought  to  be  included  in  bills  for  new 
medical  inspection  laws : 

i.  A  provision  that  the  administration  of  the  system  of  medical 
inspection  shall  be  in  the  hands  of  the  school  authorities,  but  that  they 
shall  have  the  power  to  delegate  their  authority  to  the  local  health 
officials,  and  that  in  the  treatment  of  cases  of  contagious  diseases  the 
school  and  health  authorities  shall  co-operate. 

171 


MEDICAL    INSPECTION    OF   SCHOOLS 

The  principle  here  involved  is  that  routine  medica'  inspec- 
tion and  physical  examinations  are  primarily  established  to  insure 
the  health  and  vitality  of  the  individual  child  and  are  preferably 
conducted  by  the  school  authorities  who  are  charged  with  his 
daily  care.  The  curbing  of  epidemics  of  contagious  disease  is 
primarily  for  the  protection  of  the  community,  and  in  this  the 
health  authorities  have  the  right  as  well  as  the  duty  to  intervene. 
Examples  of  such  provisions  as  those  suggested  are  to  be  found 
in  the  laws  of  North  Dakota  and  Ohio. 

2.  Provision  for  inspection  by  school  physicians  to  detect  and  ex- 
clude cases  of  contagious  disease. 

3.  Provision  for  annual  examinations  of  all  children  by  school  phy- 
sicians to  detect  any  physical  defects  which  may  prevent  the  children 
from  receiving  the  full  benefit  of  their  school  work  or  which  may  re- 
quire that  the  work  be  modified  to  avoid  injury  to  them. 

This  second  provision  should  include  the  requirement  that 
parents  be  notified  of  any  defects  discovered. 

4.  Provision  that  annual  tests  of  vision  and  hearing  shall  be  con- 
ducted by  the  teachers. 

This  provision  was  adopted  by  Massachusetts  on  the  advice 
of  the  specialists  in  these  fields  and  its  wisdom  has  been  demon- 
strated by  extensive  experience  in  that  state. 

5.  Provision  that  the  school    physicians   may  conduct   examina- 
tions of  teachers  and  janitors  and  shall  make  regular  inspections  of  the 
buildings,  premises,  and  drinking  water  to  insure  their  sanitary  condition. 

6.  Provision  that  pupils  in  normal  schools  shall  receive  training  in 
conducting  vision  and  hearing  tests. 

This  requirement  is  found  in  the  Massachusetts  law  and  the 
Minnesota  regulations. 

7.  Provision  for  the  employment  of  school  nurses. 

This  is  provided  for  in  the  laws  of  Connecticut,  Ohio, 
Pennsylvania,  and  West  Virginia. 

8.  Provision  for  the  enforcement  of  the  law. 

Such  provisions,  not  very  well  developed,  are  found  in  the 
laws  of  Colorado,  Indiana,  and  New  Jersey.  The  nature  of  the 

172 


LEGAL  PROVISIONS 

provision  must  vary  with  local  conditions.  In  states  where  muni- 
cipalities receive  a  large  part  of  their  school  funds  from  the  state, 
and  where  their  school  policies  are  consequently  largely  controlled 
through  the  state  board  of  education,  it  seems  clear  that  the 
enforcement  of  the  law  should  be  placed  in  the  hands  of  that  body. 

The  most  authoritative  formulation  of  the  features  which 
should  be  included  in  acts  providing  for  the  medical  inspection  of 
schools  is  that  embodied  in  a  series  of  resolutions  adopted  by  the 
state  and  provincial  boards  of  health  at  their  annual  meeting 
held  in  Los  Angeles,  California,  from  June  30  to  July  i,  1911. 
T^ris  body  has  for  some  years  had  a  standing  committee  on  medical 
inspection  legislation  and  has  devoted  much  time  to  the  study  of 
the  problem;  and  each  year,  for  the  past  three  years,  has  made 
reports  of  progress  at  the  annual  conference.  The  resolutions 
adopted  in  1911  are  as  follows: 

RESOLUTIONS   ADOPTED    BY  THE   CONFERENCE   OF    STATE    AND  PRO- 
VINCIAL  BOARDS   OF    HEALTH,  LOS  ANGELES,  JUNE   30- 
JULY  I,   191  I 

We  endorse  legislation  providing  for  the  medical  inspec- 
tion of  schools,  because  extended  and  varied  experience  has 
demonstrated  that  efficient  medical  inspection  betters  health 
conditions  among  school  children,  safeguards  them  from 
disease,  renders  them  healthier,  happier  and  more  vigorous, 
and  aims  to  insure  for  each  child  such  physical  and  mental 
vitality  as  will  best  enable  him  to  take  full  advantage  of  the 
free  education  offered  by  the  state. 

It  is  our  judgment  that  every  law  providing  for  the  med- 
ical inspection  of  schools  should  make  provision  for  frequent  in- 
spections of  the  children  by  duly  qualified  school  physicians  to 
detect  and  exclude  cases  of  contagious  disease. 

It  should  further  provide  for  annual  physical  examina- 
tions of  all  the  children  by  school  physicians  to  detect  any 
physical  defects  which  may  prevent  the  children  from  receiving 
the  full  benefit  of  their  school  work  or  which  may  require  that 
the  work  be  modified  to  avoid  injury  to  the  child. 

It  should  empower  school  physicians  to  conduct  examina- 
tions of  teachers  and  janitors  and  to  make  regular  inspections 
of  buildings,  premises  and  drinking  water  to  insure  their  sani- 
tary condition. 

'73 


MEDICAL    INSPECTION    OF    SCHOOLS 

We  endorse  the  school  nurse  as  a  most  valuable  ac  iunct 
of  medical  inspection  and  believe  that  provision  for  the 
employment  of  school  nurses  should  be  included  in  each  law. 


THE  MASSACHUSETTS  LAW  AND  THE  ENGLISH  ACT 

There  are  two  medical  inspection  laws  which  are  more 
important  than  any  of  the  others  as  typifying  the  legislative 
enactments  under  which  the  views  and  beliefs  and  the  results  of 
experience  of  educators  and  physicians  have  been  crystallized  in 
Europe  and  America  in  the  field  of  medical  inspection  of  schools. 
These  two  laws  are  the  English  statute  which  became  effective 
on  January  i,  1908,  and  that  of  the  state  of  Massachusetts. 
This  commonwealth,  always  foremost  in  pioneer  and  progressive 
legislation,  placed  upon  its  statute  books  in  1906  mandatory  laws 
far  more  comprehensive  in  their  provisions  than  the  English  laws. 
In  view  of  the  fact  that  these  two  laws  have  served  as  the  basis 
for  most  of  the  bills  which  have  since  been  presented  in  other 
state  and  national  legislatures,  it  seems  worth  while  to  quote 
them  in  full  here  with  some  comment  on  their  similarity  and 
differences. 

THE  ENGLISH  LAW 

The  English  law,  known  legally  as  Section  1 3  of  the  Admin- 
istrative Provisions  of  the  Education  Act  of  1907,  in  its  entirety 
is  as  follows: 

"13.  (i)  The  powers  and  duties  of  a  local  education 
authority  under  Part  III  of  the  Education  Act,  1902,  shall 
include:  (a)  Power  to  provide  for  children  attending  public 
elementary  schools,  vacation  schools,  vacation  classes,  play 
centers,  etc.  (b)  The  duty  to  provide  for  the  medical  inspec- 
tion of  children  immediately  before  or  at  the  time  of  or  as 
soon  as  possible  after  their  admission  to  a  public  elementary 
school,  and  on  such  other  occasions  as  the  Board  of  Education 
direct,  and  the  power  to  make  such  arrangements  as  may  be 
sanctioned  by  the  Board  of  Education  for  attending  to  the 
health  and  physical  condition  of  the  children  educated  in  pub- 
lic elementary  schools :  Provided,  that  in  any  exercise  of  powers 
under  this  section  the  local  education  authority  may  encourage 

'74 


LEGAL  PROVISIONS 

and  assist  the  establishment  or  continuance  of  voluntary 
agencies,  and  associate  with  itself  representatives  of  voluntary 
associations  for  the  purpose. 

"  (2)  This  section  shall  come  into  operation  on  the  first 
day  of  January,  nineteen  hundred  and  eight." 

The  English  lawmakers  are  not  quite  so  verbose  and  prolix 
in  statute  drafting  as  are  their  American  contemporaries,  and  the 
interpretation  and  construction  of  this  short  act  was  compre- 
hensively treated  by  the  Board  of  Education  in  a  memorandum 
issued  on  November  22,  1907,*  before  the  act  became  effective, 
for  the  guidance  of  the  administrative  officers  charged  with  the 
execution  of  the  statute. 

This  course  differs  somewhat  from  the  American  system. 
In  the  United  States,  the  construction  and  interpretation  of 
statutes  are  left  finally  to  the  courts.  This  procedure  is  a  lengthy 
and  involved  process.  In  view  of  the  fact  that  the  memorandum 
of  the  English  education  authorities  referred  to  has  the  practical 
effect  of  a  parliamentary  enactment  in  the  execution  of  the  law, 
it  may  be  well  to  quote  from  it  somewhat  extensively. 

In  stating  the  scope  and  purpose  of  the  act  the  memorandum 
uses  the  following  words: 

"The  Board  desire  therefore  at  the  outset  to  emphasize  that 
this  new  legislation  aims  not  merely  at  a  physical  or  anthropometric 
survey  or  at  a  record  of  defects  disclosed  by  medical  inspection,  but  at 
the  physical  improvement,  and,  as  a  natural  corollary,  the  mental  and 
moral  improvement,  of  coming  generations.  The  broad  requirements 
of  a  healthy  life  are  comparatively  few  and  elementary,  but  they  are 
essential,  and  should  not  be  regarded  as  applicable  only  to  the  case  of  the 
rich.  In  point  of  fact,  if  rightly  administered,  the  new  enactment  is 
economical  in  the  best  sense  of  the  word.  Its  justification  is  not  to  be 
measured  in  terms  of  money  but  in  the  decrease  of  sickness  and  incapacity 
among  children  and  in  the  ultimate  decrease  of  inefficiency  and  poverty 
in  after  life  arising  from  physical  disabilities." 

A  further  statement  which  concludes  the  same  section  of  the 
memorandum  is  as  follows : 

*  Board  of  Education  of  Great  Britain.  Memorandum  on  Medical  Inspec- 
tion of  Children  in  Public  Elementary  Schools,  Circular  576. 

175 


MEDICAL    INSPECTION    OF    SCHOOLS 

"It  is  founded  on  a  recognition  of  the  close  connection  which 
exists  between  the  physical  and  mental  condition  of  the  children  and  the 
whole  process  of  education.  It  recognizes  the  importance  of  a  satis- 
factory environment,  physical  and  educational,  and,  by  bringing  into 
greater  prominence  the  effect  of  environment  upon  the  personality  of 
the  individual  child,  seeks  to  secure  ultimately  for  every  child,  normal 
or  defective,  conditions  of  life  compatible  with  that  full  and  effective 
development  of  its  organic  functions,  its  special  senses  and  its  mental 
powers  which  constitutes  a  true  education." 

It  will  be  observed  that  the  burden  of  executing  the  pro- 
visions of  the  statute  is  specifically  laid  upon  the  education  author- 
ities. This  is  a  distinct  departure  from  the  established  course 
heretofore  pursued  in  matters  relating  to  the  public  health.  In 
the  view  of  the  English  Board  of  Education,  however,  the 
present  act  is  not  intended  to  supersede  the  powers  which  have 
long  been  exercised  by  sanitary  authorities  under  various  public 
health  acts,  but  is  meant  to  serve  rather  as  an  amplification  and 
a  natural  development  of  previous  legislation.  In  order  that 
friction  between  the  education  and  health  authorities  may  be 
avoided,  if  possible,  the  board  of  education  in  this  memorandum 
advises  a  thorough  and  friendly  co-operation  with  such  authorities 
in  the  administration  of  the  law. 

The  second  most  noticeable  feature  about  the  act  is  that 
it  makes  medical  inspection  compulsory.  Theretofore,  medical 
inspection  had  been  more  or  less  in  vogue  in  various  localities 
under  the  supervision  of  the  education  authorities,  sometimes  in 
conjunction  with  the  health  authorities.  The  central  authority 
for  the  execution  of  the  law  is  the  board  of  education.  The 
instruments  of  the  board  are  the  local  education  authorities.  In 
country  areas  this  local  authority  is  the  county  council.  It  is 
suggested  in  the  memorandum  that  the  county  council  instruct 
the  county  medical  officer  to  advise  the  education  committee 
and  to  supervise  the  new  work.  It  is  also  suggested  that  the 
county  medical  officer  have  an  assistant  appointed  by  the  county 
council,  whose  duty  shall  be  the  inspection  provided  for  by  the 
statute. 

In  county  boroughs  the  town  council,  which  is  at  the  same 
time  the  local  authority  for  public  health  and  the  local  education 

176 


LEGAL  PROVISIONS 

authority,  is  counseled  to  instruct  their  medical  officer  of  health 
to  advise  the  education  committee  and  assume  responsibility  for 
the  new  work.  Where  no  school  medical  officer  has  been  appointed, 
it  is  suggested  that  his  appointment  be  made  by  the  education 
authorities.  Where  there  are  already  school  medical  officers  it  is 
suggested  that  they  be  retained  if  competent  and  sufficient  for 
the  new  duties. 

Although  there  is  no  provision  for  school  nurses  in  the  act, 
the  board  of  education  advises  that  wherever  practicable  such 
nurses  be  employed. 

The  board  decided  that  not  less  than  three  inspections  during 
the  school  life  of  a  child  would  be  necessary  to  secure  the  results 
desired.  In  certain  areas,  the  board  may  from  time  to  time 
require  inspection  at  shorter  intervals  and  of  a  more  searching 
character. 

The  inspection  of  the  sanitation  of  school  buildings,  the 
prevention  of  the  spread  of  contagious  diseases,  and  the  super- 
vision of  the  personal  and  home  life  of  the  child  are  also  suggested. 

Finally,  it  should  be  observed  that  neither  the  act  nor  the 
memorandum  contains  any  section  whatever  requiring  that 
parents  of  school  children  found  diseased  or  defective  after  such 
inspection  shall  be  compelled  to  provide  proper  medical  attention 
at  the  hands  of  their  own  physician  or  of  the  hospital  authorities.* 
As  a  means  of  securing  the  co-operation  of  parents  the  memoran- 
dum recommends  "that  each  local  educational  authority  should 
encourage  one  or  both  of  the  parents  of  the  child  to  be  present 
at  the  first  inspection,  and  to  this  end  a  notification  should  be 
sent  to  the  parents  as  to  the  time  and  place  at  which  it  will  take 
place." 

THE  MASSACHUSETTS  LAW 

Let  us  now  consider  for  comparison  with  the  English  statute 
the  first  legislative  enactment  in  the  United  States  which  made 
medical  inspection  mandatory.  As  this  Massachusetts  law  was 
the  initial  legislative  effort  in  America  along  this  line,  it  seems 
worth  while  to  quote  it  in  extenso.  Legally  it  is  known  as  Chapter 

*  See  Chap.  VI,  p.  86,  for  information  regarding  compulsory  action  taken 
in  England. 

12  I 


MEDICAL    INSPECTION    OF    SCHOOLS 

502  of  the  Acts  of  1906,  and  it  became  a  law  of  the  state  of  Mass- 
achusetts on  the  first  day  of  September,  1906.     It  provides: 

APPOINTMENT   OF    SCHOOL    PHYSICIANS,    ETC. 

Section  i.  The  school  committee  of  every  city  and 
town  in  the  Commonwealth  shall  appoint  one  or  more  school 
physicians,  shall  assign  one  to  each  public  school  within  its 
city  or  town,  and  shall  provide  them  with  all  proper  facilities 
for  the  performance  of  their  duties  as  prescribed  in  this  act: 
provided,  however,  that  in  cities  wherein  the  board  of  health 
is  already  maintaining  or  shall  hereafter  maintain  substantially 
such  medical  inspection  as  this  act  requires,  the  board  of 
health  shall  appoint  and  assign  the  school  physician. 

EXAMINATION    AND   DIAGNOSIS   TO    BE    MADE 

Section  2.  Every  school  physician  shall  make  a  prompt 
examination  and  diagnosis  of  all  children  referred  to  him  as 
hereinafter  provided,  and  such  further  examination  of  teachers, 
janitors,  and  school  buildings  as  in  his  opinion  the  protection 
of  the  health  of  the  pupils  may  require. 

AUTHORITY   OF    SCHOOL   COMMITTEES,    ETC. 

Section  3.  The  school  committee  shall  cause  to  be 
referred  to  a  school  physician  for  examination  and  diagnosis 
every  child  returning  to  school  without  a  certificate  from  the 
board  of  health  after  absence  on  account  of  illness  or  from 
unknown  cause;  and  every  child  in  the  schools  under  its 
jurisdiction  who  shows  signs  of  being  in  ill  health  or  of  suffering 
from  infectious  or  contagious  disease,  unless  he  is  at  once  ex- 
cluded from  school  by  the  teacher;  except  that  in  the  case  of 
schools  in  remote  and  isolated  situations  the  school  commit- 
tee may  make  such  other  arrangements  as  may  best  carry  out 
the  purposes  of  this  act. 

NOTICE  TO  BE  SENT  TO  PARENT  OR  GUARDIAN 

Section  .4.  The  school  committee  shall  cause  notice  of 
the  disease  or  defects,  if  any,  from  which  any  child  is  found 
to  be  suffering  to  be  sent  to  his  parent  or  guardian.  Whenever 
a  child  shows  symptoms  of  smallpox,  scarlet  fever,  measles, 
chickenpox,  tuberculosis,  diphtheria  or  influenza,  tonsilitis, 
whooping  cough,  mumps,  scabies,  or  trachoma,  he  shall  be 
sent  home  immediately,  or  as  soon  as  safe  and  proper  con- 

.78 


LEGAL  PROVISIONS 

veyance  can  be  found,  and  the  board  of  health  shall  at  once  be 
notified. 

TESTS    OF    SIGHT    AND    HEARING    AND    EXAMINATION    FOR    DIS- 
ABILITY  OR   DEFECTS 

Section  5.  The  school  committee  of  every  city  and 
town  shall  cause  every  child  in  the  public  schools  to  be  sepa- 
rately and  carefully  tested  and  examined  at  least  once  in  every 
school  year  to  ascertain  whether  he  is  suffering  from  defective 
sight  or  hearing  or  from  any  other  disability  or  defect  tending 
to  prevent  his  receiving  the  full  benefit  of  his  school  work,  or 
requiring  a  modification  of  the  school  work  in  order  to  pre- 
vent injury  to  the  child  or  to  secure  the  best  educational  re- 
sults. The  tests  of  sight  and  hearing  shall  be  made  by  teachers. 
The  committee  shall  cause  notice  of  any  defect  or  disability  re- 
quiring treatment  to  be  sent  to  the  parent  or  guardian  of  the 
child,  and  shall  require  a  physical  record  of  each  child  to  be 
kept  in  such  form  as  the  state  board  of  education  shall  pre- 
scribe. 

STATE    BOARD    OF    HEALTH    TO    PRESCRIBE    DIRECTIONS:     STATE 
BOARD  OF   EDUCATION  TO   FURNISH   RULES,   ETC. 

Section  6.  The  state  board  of  health  shall  prescribe  the 
directions  for  tests  of  sight  and  hearing  and  the  state  board 
of  education  shall,  after  consultation  with  the  state  board 
of  health,  prescribe  and  furnish  to  school  committees  suitable 
rules  of  instruction,  test  cards,  blanks,  record  books,  and 
other  useful  appliances  for  carrying  out  the  purposes  of  this 
act,  and  shall  provide  for  pupils  in  the  normal  schools  instruc- 
tion and  practice  in  the  best  methods  of  testing  the  sight  and 
hearing  of  children.  The  state  board  of  education  may 
expend  during  the  year  nineteen  hundred  and  six  a  sum  not 
greater  than  fifteen  hundred  dollars  and  annually  thereafter  a 
sum  not  greater  than  five  hundred  dollars*  for  the  purpose  of 
supplying  the  material  required  by  this  act. 

The  English  statute  and  the  Massachusetts  one  are  simi- 
lar in  that  both  make  medical  inspection  compulsory,  both  place 
the  administration  in  the  hands  of  the  educational  authorities, 
and  that  neither  provides  for  procedure  against  neglectful  par- 
ents of  defective  children.  They  prescribe  different  methods  of 

*  Eight  hundred  dollars  now  appropriated  under  Chapter  189,  Acts  of  1908. 

179 


MEDICAL   INSPECTION   OF   SCHOOLS 

securing  the  co-operation  of  parents  for  the  correction  of  defects, 
the  Massachusetts  law  requiring  that  notices  of  the  results  of 
inspections  be  sent,  while  the  English  memorandum  recommends 
the  summoning  of  parents  to  be  present  at  the  inspections.  In 
the  English  statute  there  is  no  express  provision  as  to  the 
frequency  of  physical  examinations,  but  as  has  been  stated,  the 
memorandum  of  the  board  of  education  prescribes  three  examina- 
tions as  necessary  during  the  school  life  of  the  pupil.  In  the 
Massachusetts  statute  an  examination  of  every  pupil  at  least 
once  in  every  year  for  defective  sight  or  hearing  and  any  other 
physical  disabilities,  is  provided  for.  The  sight  and  hearing  tests 
are  given  by  teachers,  while  the  other  examinations  are  conducted 
by  physicians. 

These  are  the  leading  statutes  ot  Europe  and  America  on 
this  subject.  At  the  close  of  1912  the  American  statute  will 
have  been  in  effect  for  six  years  and  the  English  statute  for  five. 
Both  of  these  pieces  of  legislation  may  therefore  be  considered  as 
having  passed  through  the  experimental  stage. 


1 80 


APPENDICES 


APPENDIX  I 

SUGGESTIONS  TO  TEACHERS  AND  SCHOOL  PHYSI- 
CIANS REGARDING  MEDICAL  INSPECTION 

Issued  by  the  Massachusetts  Board  of  Education 

COMMONWEALTH  OF  MASSACHUSETTS 
STATE  HOUSE,  BOSTON,  Jan.  23,  1907 

In  order  to  render  the  medical  inspection  required  by  chapter  502, 
Acts  of  1906,  effective  and  uniform  throughout  the  State,  His  Excel- 
lency Governor  Guild  appointed  a  committee  to  prepare  a  circular  of 
advice  to  the  school  physicians  of  the  State. 

This  committee  consisted  of  Dr.  Henry  P.  Walcott,  Dr.  Charles 
Harrington  and  Dr.  Julian  A.  Mead,  representing  the  State  Board  of 
Health;  Mrs.  Ella  Lyman  Cabot,  Mr.  George  I.  Aldrich  and  Mr.  George 
H.  Martin,  representing  the  Board  of  Education;  and  Dr.  Robert  W. 
Lovett,  Dr.  Harold  Williams  and  Dr.  W.  H.  Devine,  representing  the 
medical  profession. 

A  sub-committee  of  this  body  arranged  for  conferences  with  the 
heads  of  departments  and  others  connected  with  the  medical  schools  and 
hospitals  in  and  about  Boston,  and  with  physicians  who  have  had  ex- 
perience in  school  inspection.  These  gentlemen  have  given  freely  of  their 
time  and  thought,  and  have  furnished  to  the  committee  the  suggestions 
contained  in  this  circular. 

These  suggestions  cover  the  ground  included  in  the  clause  in  section 
5  of  the  law:  "The  school  committee  of  every  city  and  town  shall  cause 
every  child  in  the  public  schools  to  be  separately  and  carefully  tested 
and  examined  at  least  once  in  every  school  year,  to  ascertain  whether 
he  is  suffering  from  defective  sight  or  hearing,  or  from  any  other  dis- 
ability or  defect  tending  to  prevent  his  receiving  the  full  benefit  of  his 
school  work,  or  requiring  a  modification  of  the  school  work  in  order  to 
prevent  injury  to  the  child  or  to  secure  the  best  educational  results." 

The  Board  of  Education  issues  this  circular  in  the  assurance  that 
it  represents  the  highest  professional  authority  in  the  specialties  covered 
by  the  law,  and  commends  it  to  the  careful  attention  of  all  teachers, 
school  physicians  and  other  school  officers. 


MEDICAL   INSPECTION   OF   SCHOOLS 

The  following  are  the  subjects  treated,  with  the  names  of  the  physi- 
cians who  have  contributed  suggestions: 

1.  Infectious  Diseases. — Dr.  John  H.  McCollom. 

2.  The  Eye.— Dr.  Myles  Standish,  Dr.  Henry  B.  Chandler,  Dr. 
Charles  H.  Williams,  Dr.  David  W.  Wells. 

3.  The  Ear.— Dr.  Clarence  J.  Blake,  Dr.  D.  Harold  Walker. 

4.  The  Throat  and  Nose. — Dr.  Samuel  W.  Langmaid,  Dr.  Algernon 
Coolidge,  Jr.,  Dr.  Frederic  C.  Cobb,  Dr.  George  B.  Rice. 

5.  The  Skin. — Dr.  John  T.  Bowen,  Dr.  James  S.  Howe,  Dr.  George 
F.  Harding,  Dr.  Charles  J.  White,  Dr.  C.  Morton  Smith,  Dr.  John  L. 
Coffin. 

6.  Diseases  of  Bones  and  Joints. — Dr.  Edward  H.  Bradford,  Dr. 
Augustus  Thorndike,  Dr.  Charles  F.  Painter,  Dr.  George  H.  Earl,  Dr. 
Robert  Soutter. 

7.  Children's   Diseases. — Dr.   Thomas    M.    Rotch,    Dr.   John   L. 
Morse,  Dr.  John  H.  Moore,  Dr.  Robert  W.  Hastings,  Dr.  Edmund  C. 
Stowell. 

8.  The  Teeth. — Dr.  Edward  W.  Branigan,  Dr.  George  A.  Bates, 
Dr.  Eugene  H.  Smith,  Dr.  Samuel  A.  Hopkins. 

9.  Nervous  Diseases. — Dr.  James  J.  Putnam,  Dr.  George  L.  Walton, 
Dr.  Morton  Prince,  Dr.  William  N.  Bullard,  Dr.  Edward  W.  Taylor, 
Dr.  John  J.  Thomas,  Dr.  Walter  E.  Fernald. 

10.  School  Hygiene. — Dr.  Henry  J.  Barnes. 

11.  School  Furniture. — Dr.  Frederick  J.  Cotton,  Dr.  R.  Clipston 
Sturgis. 

12.  School  Inspectors. — Dr.  George  S.  C.  Badger,  Dr.  H.  Lincoln 
Chase,  Dr.  Harry  M.  Cutts. 

GEORGE  H.  MARTIN, 

Secretary. 

DISEASES 
INFECTIOUS  DISEASES 

Diphtheria. — It  is  a  well-recognized  fact  that  nasal  diphtheria  of  a 
mild  type  without  constitutional  disturbance  is  one  of  the  most  impor- 
tant factors  in  causing  the  spread  of  the  disease,  and  also  that  children 
very  frequently  have  profuse  discharges  from  the  nose.  It  therefore 
follows  that,  in  order  properly  to  inspect  the  public  schools,  it  is  impor- 
tant that  cultures  should  be  taken  from  the  nose  in  every  case  where 
there  is  a  persistent  discharge,  particularly  if  there  is  any  excoriation 
about  the  nostrils. 

The  throat  should  be  examined  at  varying  intervals,  depending 

184 


APPENDIX    I 

upon  the  physical  condition  of  the  children.  Any  hoarseness  or  any  thick- 
ness of  the  voice  should  cause  an  examination  of  the  throat.  If  the  tonsils 
are  enlarged,  if  the  mucous  membrane  is  congested,  if  there  is  swelling  of 
palate,  a  culture  should  be  taken.  These  symptoms  precede  diphtheria. 

A  child  with  positive  cultures  should  be  excluded  from  school  until 
two  consecutive  negative  cultures  at  an  interval  of  forty-eight  hours 
have  been  obtained. 

Scarlet  Fever. — If  there  is  a  sudden  attack  of  vomiting,  if  there  is 
any  redness  of  the  throat,  if  the  child  complains  of  headache,  if  there 
is  an  unexplained  rise  in  temperature,  the  child  should  be  isolated  at 
once.  Any  desquamation  (peeling  of  the  skin)  should  be  looked  upon 
with  suspicion.  If  there  are  any  breaks  at  the  finger  tips,  if  on  pressing 
the  pulp  of  the  finger  there  is  a  white  line  at  the  juncture  of  the  nail 
with  the  pulp  of  the  finger,  particularly  if  this  occurs  in  the  majority 
of  the  finger  tips,  the  child  should  be  excluded  from  the  school. 

A  child  who  has  had  scarlet  fever  should  not  return  to  school  until 
the  process  of  desquamation  has  been  entirely  completed,  and  all  dis- 
charge from  the  nose  and  ears  has  ceased. 

Measles. — Running  from  the  nose  and  slight  intolerance  of  light 
may  call  for  an  examination  of  the  mucous  membrane  of  the  mouth  for 
Koplik's  sign.  Koplik's  sign,  so  called,  is  the  presence  on  the  lining 
membrane  of  the  mouth,  near  the  molar  teeth,  of  minute  pearly  white 
blisters,  without  any  inflammation  around  them.  There  may  be  only 
two  or  three  of  these  blisters,  and  they  may  easily  escape  detection  if  the 
patient  is  not  carefully  examined  in  a  good  light.  These  blisters  are 
certain  forerunners  of  an  attack  of  measles. 

No  child  should  return  to  school  after  an  attack  of  measles  until 
the  desquamation  is  entirely  completed,  and  the  child  has  recovered 
from  the  intercurrent  bronchitis. 

Mumps. — Any  swelling  or  tenderness  in  the  region  of  the  parotid 
glands  (situated  behind  the  angle  of  the  jaw)  should  be  looked  upon 
with  suspicion.  It  is  important  to  notice  any  enlargement  or  swelling 
about  Steno's  duct  (inside  the  mouth,  opposite  the  second  upper  molar 
tooth),  as  this  is  a  very  frequent  symptom  of  mumps. 

A  child  should  be  excluded  from  school  until  one  week  has  elapsed 
after  the  disappearance  of  all  swelling  and  tenderness  in  the  region  of 
the  parotid  glands. 

Wbooping-cougb. — A  persistent  paroxysmal  cough,  frequently  ac- 
companied with  vomiting,  no  matter  whether  there  is  any  distinct  whoop 
or  not,  is  indicative  of  whooping-cough.  In  cases  of  whooping-cough 
of  long  standing,  even  if  there  has  been  no  distinct  whoop,  an  ulcer  on 

185 


MEDICAL   INSPECTION   OF   SCHOOLS 

the  band  connecting  the  lower  surface  of  the  tongue  with  the  floor  of  the 
mouth  is  found  in  a  certain  number  of  cases.  If  there  is  no  distinct 
ulceration,  there  may  be  a  marked  congestion  of  the  band. 

As  long  as  there  is  any  cough,  the  child  who  has  had  whooping- 
cough  should  be  looked  upon  with  suspicion. 

Varicella  (Chicken  Pox). — A  few  black  crusts  scattered  over  the 
bodv  are  evidences  of  an  attack  of  chicken  pox .  The  crusting  seen  in 
impetigo  must  be  differentiated  from  that  of  chicken  pox.* 

No  child  should  return  to  school  until  all  crusts  have  disappeared 
from  the  body,  particularly  from  the  scalp,  for  in  this  region  the  crusts 
remain  longer  than  elsewhere. 

THE  EYES 
[Supplement  to  circular  already  issued  f] 

There  are  certain  children  who  show  normal  vision  by  the  ordinary 
tests,  yet  whose  parents  should  be  notified  to  have  the  eyes  examined. 
These  are:  (i)  children  who  habitually  hold  the  head  too  near  the  book 
(less  than  twelve  to  fourteen  inches);  (2)  children  who  frequently  com- 
plain of  headaches,  especially  in  the  latter  portion  of  school  hours;  (3) 
children  in  whom  one  eye  deviates  even  temporarily  from  the  normal 
position. 

It  should  be  remembered  that  the  following  symptoms  are  at  times 
indicative  of  trouble  with  the  eyes:  (i)  habitual  scowling,  and  wrinkling 
of  the  forehead  when  reading  or  writing;  (2)  twitching  of  the  face; 
(3)  inattention  and  slowness  in  book  studies  in  a  child  otherwise  bright. 

THE  EARS 

See  circular  of  directions  f  for  testing  hearing,  already  in  hands  of 
teachers. 

THE  THROAT  AND  NOSE 

In  all  cases  of  acute  illness  the  throat  should  be  examined  for  the 
presence  of  the  eruption  of  scarlet  fever  and  measles  and  for  the  exuda- 
tion or  membrane  of  tonsilitis  and  diphtheria,  and  a  culture  taken  in 
any  suspected  case  of  the  latter. 

The  presence  of  discharge  from  the  nose  should  be  noted,  and 
if  it  is  thick  and  creamy,  a  culture  should  always  be  taken.  In  all  cases 
of  severe  hoarseness,  with  difficult  breathing,  diphtheria  should  be  sus- 

*  See  Diseases  of  the  Skin. 

f  See  pp.  45-47  for  this  circular. 

1 86 


APPENDIX    I 

pected.  If  the  discharge  from  the  nose  is  only  from  one  nostril,  a  foreign 
body  in  the  nose  should  be  looked  for. 

In  cases  of  chronic  nasal  obstruction,  as  evinced  by  mouth-breath- 
ing, snoring,  continual  post-nasal  catarrh  or  recurring  ear  trouble,  the 
presence  of  an  adenoid  growth  (third  tonsil)  should  be  suspected,  and 
the  child  referred  for  special  examination  and  treatment.  As  a  rule, 
digital  examination  for  adenoids  should  be  made  only  by  the  operating 
surgeon.  Obviously  large  tonsils,  recurring  tonsilitis  and  enlargement 
of  the  glands  of  the  neck,  suggest  the  advisability  of  referring  the  child 
to  the  family  physician  as  to  the  propriety  of  removing  the  tonsils. 

Recurring  nose-bleed  should  be  referred  for  special  treatment. 

In  cases  of  eczema  about  the  nostrils,  a  cause  may  be  sought  in 
pediculi  capitis  (head  lice). 

In  referring  cases  for  treatment,  school  physicians,  in  addition  to 
the  diagnosis,  should  state  the  symptoms  upon  which  the  diagnosis  is 
based,  for  the  benefit  of  the  family  physician  or  specialist. 

DISEASES  OF  THE  SKIN 

Scabies  (the  Itch). — A  contagious  skin  disease,  due  to  an  animal 
parasite  which  burrows  in  the  skin,  causing  intense  itching  and  scratch- 
ing. The  disease  usually  begins  upon  the  hands  and  arms,  spreading 
over  the  whole  body,  but  does  not  affect  the  face  and  scalp.  Between 
the  fingers,  on  the  front  of  the  wrist,  at  the  bend  of  the  elbows  and  near 
the  arm-pits  are  favorite  locations  for  the  disease;  but  in  persons  of 
cleanly  habits  the  disease  may  not  show  at  all  upon  the  hands,  and  its 
real  nature  is  determined  only  after  a  most  thorough  and  careful  examina- 
tion. There  is  a  great  variation  in  the  extent  and  severity  of  this  disease, 
lack  of  personal  care  and  cleanliness  always  favoring  its  development. 
Scratching  soon  brings  about  an  infection  of  the  skin  with  some  of  the 
pus-producing  germs,  and  the  disease  is  then  accompanied  by  impetigo, 
or  a  pus  infection  of  the  skin. 

At  the  present  time  itch  is  very  common  and  widespread,  and, 
because  of  the  great  variation  in  its  severity,  mild  cases  have  been  mis- 
taken for  hives,  eczema,  etc.,  the  real  condition  not  being  recognized, 
and  the  disease  spread  in  consequence.  All  children  who  are  scratching 
or  have  an  irritation  upon  the  skin  should  be  examined  for  scabies. 

It  is  very  important  that  all  infected  members  of  a  family  be  treated 
till  cured,  else  the  disease  is  passed  back  and  forth  from  one  to  another. 
It  is  also  important  that  all  underclothing,  bedding,  towels,  etc.,  things 
that  come  in  contact  with  the  body,  be  boiled  when  washed. 

All  cases  of  scabies  should  be  excluded  from  school  until  cured. 

.87 


MEDICAL   INSPECTION    OF    SCHOOLS 

Pediculi  Capitis  (Head  Lice). — An  extremely  common  accident 
among  children,  either  from  wearing  each  others'  hats  and  caps,  or  hanging 
them  on  each  others'  pegs,  or  from  combs  and  brushes.  No  person  should 
be  blamed  for  having  lice, — only  for  keeping  them. 

The  irritation  caused  by  vermin  in  the  scalp  leads  to  scratching, 
which  in  turn  causes  an  inflammation  of  the  skin  of  the  neck  and  scalp. 
The  skin  then  easily  becomes  infected  with  some  of  the  pus-producing 
germs,  and  large  or  small  scabs  and  crusts  are  formed  from  the  dried 
matter  and  blood.  Along  with  this  condition  the  glands  back  of  the 
ears  and  in  the  neck  become  swollen,  and  may  be  very  painful  and  tender. 

The  condition  of  pediculosis  is  most  easily  detected  by  looking  for 
the  eggs  (nits),  which  are  always  stuck  onto  the  hair,  and  are  not  readily 
brushed  off.  The  condition  is  best  treated  by  killing  the  living  parasites 
with  crude  petroleum,  and  then  getting  rid  of  the  nits.  With  boys, 
this  is  easy, — a  close  hair  cut  is  all  that  is  needed;  with  girls,  by  using 
a  fine-toothed  comb  wet  in  alcohol  or  vinegar,  which  dissolves  the  attach- 
ment of  the  eggs  to  the  hair.  All  combs  and  brushes  must  be  carefully 
cleansed. 

Children  with  pediculosis  should  be  excluded  from  school  until  their 
heads  are  clean.  By  chapter  383,  Acts  of  1906,  parents  who  neglect 
or  refuse  to  care  for  their  children  in  this  respect  may  be  prosecuted 
under  the  compulsory  attendance  law. 

Ringworm. — A  vegetable  parasitic  disease  of  the  skin  and  scalp. 
When  it  occurs  upon  the  skin,  it  yields  readily  to  treatment;  but  upon 
the  scalp  it  is  extremely  chronic.  Ringworm  of  the  skin  usually  appears 
on  the  face,  hands  or  arms, — rarely  upon  the  body, — in  varying  sized 
more  or  less  perfect  circles.  One  or  more,  usually  not  widely  separated, 
may  be  present  at  the  same  time.  All  ringed  eruptions  upon  the  skin 
should  be  examined  for  ringworm. 

When  the  disease  attacks  the  scalp,  the  hairs  fall  or  break  off  near 
the  scalp,  leaving  dime  to  dollar  sized  areas  nearly  bald.  The  scalp  in 
these  areas  is  usually  dry  and  somewhat  scaly,  but  may  be  swollen  and 
crusted.  The  disease  spreads  at  the  circumference  of  the  area,  and 
new  areas  arise  from  scratching,  etc. 

Another  disease,  somewhat  like  ringworm  of  the  scalp,  is  known  as 
favus, — a  disease  much  more  common  in  Europe  than  America.  In 
this  disease  quite  abundant  crusts  of  a  yellowish  color  are  present  where 
the  process  is  active.  The  roots  of  the  hair  are  killed,  so  that  the  loss 
of  hair  from  this  disease  is  permanent,  a  scar  remaining  when  the  condi- 
tion is  cured. 


1 88 


APPENDIX    I 

Care  must  be  taken  to  see  that  all  combs  and  brushes  are  thoroughly 
cleansed,  and  to  prevent  children  wearing  each  others'  hats,  caps,  etc. 

Children  with  ringworm  should  not  be  allowed  to  attend  school. 

Impetigo. — A  disease  characterized  by  few  or  many  large  or  small 
flat  or  elevated  pustules  or  festers  upon  the  skin.  The  condition  is  often 
secondary  to  irritation  or  itching  diseases  of  the  skin  (hives,  lice,  itch), 
and  scratching  starts  up  a  pus  infection. 

The  disease  most  often  appears  upon  the  face,  neck,  and  hands, 
less  often  upon  the  body  and  scalp.  The  size  of  the  spots  varies  very 
much,  and  they  often  run  together  to  form  on  the  face  large  superficial 
sores,  covered  with  thick,  dirty,  yellowish  or  brownish  crusts. 

The  disease  is  contagious,  and  often  spread  by  towels  and  things 
handled. 

Children  having  impetigo  should  not  be  allowed  to  attend  school 
until  all  sores  are  healed  and  the  skin  is  smooth. 

DISEASES  OF  THE  BONES  AND  JOINTS 

All  noticeable  lameness,  whether  sudden  or  continued,  may  indicate 
serious  joint  trouble,  or  may  be  due  to  improper  shoes.  These  cases, 
as  well  as  curvatures  of  the  spine,  as  indicated  by  habitual  faulty  postures 
at  the  desk  or  in  walking,  should  be  referred  for  medical  inspection. 

Spinal  curvature  should  be  suspected  when  one  shoulder  is  habitu- 
ally raised  or  dropped,  or  when  the  child  leans  to  the  side,  or  shows  per- 
sistent round  shoulders. 

Complaints  of  persistent  "growing  pains"  or  "rheumatism"  may 
be  the  earliest  signs  of  serious  disease  of  the  joints. 

SOME  GENERAL  SYMPTOMS  OF  DISEASE  IN  CHILDREN  WHICH  TEACHER 
SHOULD  NOTICE,  AND  ON  ACCOUNT  OF  WHICH  THE  CHILDREN 
SHOULD  BE  REFERRED  TO  THE  SCHOOL  PHYSICIAN 

Emaciation. — This  is  a  manifestation  of  many  chronic  diseases, 
and  may  point  especially  to  tuberculosis. 

Pallor. — Pallor  usually  indicates  anemia.  Pallor  in  young  girls 
usually  means  chlorosis, — a  form  of  anemia  peculiar  to  girls  at  about 
the  age  of  puberty.  It  is  usually  associated  with  shortness  of  breath; 
the  general  condition  otherwise  usually  appears  good.  Pallor  may 
also  be  a  manifestation  of  disease  of  the  kidneys;  this  is  almost  invariably 
the  case  if  it  is  associated  with  puffmess  of  the  face. 

Puffiness  of  the  Face. — This,  especially  if  it  is  about  the  eyes,  points 
to  disease  of  the  kidneys;  it  may,  however,  merely  indicate  nasal  ob- 
struction. 


MEDICAL   INSPECTION    OF   SCHOOLS 

Shortness  of  Breath. — Shortness  of  breath  usually  indicates  disease 
of  the  heart  or  lungs.  If  it  is  associated  with  blueness,  the  trouble  is 
usually  in  the  heart.  If  it  is  associated  with  cough,  the  trouble  is  more 
likely  to  be  in  the  lungs. 

Swellings  in  the  Neck. — These  may  be  due  to  mumps  or  enlarge- 
ment of  the  glands.  The  swelling  of  mumps  comes  on  acutely,  and  is 
located  just  behind,  just  in  front  and  below  the  ear.  Swollen  glands 
are  situated  lower  in  the  neck,  or  about  the  angle  of  the  jaw.  They  may 
come  on  either  acutely  or  slowly.  If  acutely,  they  mean  some  acute 
condition  in  the  throat.  If  slowly,  they  are  most  often  tubercular. 
They  may  also  be  the  result  of  irritation  of  the  scalp  or  lice  in  the  hair. 

General  Lassitude,  and  Other  Evidences  of  Sickness. — These  hardly 
need  description,  but  may,  of  course,  mean  the  presence  or  onset  of  any 
of  the  acute  diseases. 

Flushing  of  the  Face. — This  very  often  means  fever,  and  on  this 
account  should  be  reported. 

Eruptions  of  any  Sort. — All  eruptions  should  be  called  to  the  atten- 
tion of  the  physician.  It  is  especially  important  to  notice  eruptions, 
because  they  may  be  the  manifestations  of  some  of  the  contagious  diseases. 
The  eruption  of  scarlet  fever  is  of  a  bright  scarlet  color,  and  usually 
appears  first  on  the  neck  and  chest,  spreading  thence  to  the  face.  There 
is  often  a  pale  ring  about  the  mouth  in  scarlet  fever,  which  is  very  charac- 
teristic. There  is  usually  a  sore  throat  in  connection  with  the  eruption. 
The  eruption  of  measles  is  a  rose  or  purplish  red,  and  is  in  blotches  about 
the  size  of  a  pea.  It  appears  first  on  the  face,  and  is  usually  associated 
with  running  of  the  nose  and  eyes.  The  eruption  of  chicken  pox  appears 
first  as  small  red  pimples,  which  quickly  become  small  blisters. 

A  Cold  in  the  Head,  with  Running  Eyes. — This  should  be  noticed, 
because  it  may  indicate  the  onset  of  measles. 

Irritating  Discharge  from  the  Nose. — A  thin,  watery  nasal  discharge, 
which  irritates  the  nostrils  and  the  upper  lip,  should  always  be  regarded 
with  suspicion.  It  may  mean  nothing  more  than  a  cold  in  the  head, 
but  not  infrequently  indicates  diphtheria. 

Evidences  of  Sore  Throat. — Evidences  of  sore  throat,  such  as  swelling 
of  the  neck  and  difficulty  in  swallowing,  are  of  importance.  They  may 
mean  nothing  but  tonsilitis,  but  are  not  infrequently  manifestations 
of  diphtheria  or  scarlet  fever. 

Coughs. — It  is  very  important  to  notice  whether  children  are  cough- 
ing or  not,  and  what  is  the  character  of  the  cough.  In  most  cases,  of 
course,  the  cough  merely  means  a  simple  cold  or  slight  bronchitis.  A 
spasmodic  cough,  that  is,  a  cough  which  occurs  in  paroxysms  and  is 

190 


APPENDIX    I 

uncontrollable,  very  frequently  indicates  whooping-cough.  A  croupy 
cough,  that  is,  a  cough  which  is  harsh  and  ringing,  may  indicate  the 
disease  diphtheria.  A  painful  cough  may  indicate  disease  of  the  lungs, 
especially  pleurisy  or  pneumonia.  A  long-continued  cough  may  mean 
tuberculosis  of  the  lungs. 

Vomiting. — Vomiting  usually,  of  course,  merely  means  some  di- 
gestive upset.  It  may,  however,  be  the  initial  symptom  of  many  of 
the  acute  diseases,  and  is  therefore  of  considerable  importance. 

Frequent  Requests  to  go  out. — Teachers  are  too  much  inclined  to 
think  that  frequent  requests  to  go  out  merely  indicate  restlessness  or 
perversity.  They  often,  however,  indicate  trouble  of  some  sort,  which 
may  be  in  the  bowels,  kidneys  or  bladder;  therefore,  they  should  always 
be  reported  to  the  physician. 

THE  TEETH 

Unclean  mouths  promote  the  growth  of  disease  germs,  and  cavities 
in  the  teeth  are  centers  of  infection.  Pus  from  diseased  teeth  seriously 
interferes  with  digestion  and  poisons  the  system.  It  causes  a  lowering 
of  vitality  and  renders  mental  effort  difficult.  Diseased  teeth,  tempo- 
rary as  well  as  permanent,  are  frequently  the  cause  of  abscesses,  and 
should  be  carefully  watched  and  treated. 

Irregularities  of  the  teeth,  especially  those  which  make  it  impossible 
to  close  the  teeth  properly,  lead  to  faulty  digestion,  to  mouth-breathing, 
and  to  other  diseases  and  evils  which  an  insufficient  supply  of  oxygen 
produces. 

The  first  permanent  molars  are  perhaps  the  most  important  teeth 
in  the  mouth,  and  are  the  most  frequently  neglected,  because  they  are 
so  often  mistaken  for  temporary  teeth.  (It  should  be  remembered 
that  there  are  twenty  temporary  teeth,  ten  in  each  jaw,  and  that  the 
teeth  that  come  at  about  the  sixth  year  immediately  behind  each  last 
temporary  tooth — four  in  all — are  the  first  permanent  molars.) 

The  teacher  should  be  on  the  lookout  for  pain  or  swelling  in  the  face. 
When  the  child  keeps  the  mouth  constantly  open,  an  examination  of 
the  teeth  should  be  made.  When  symptoms  of  indigestion  occur,  or 
physical  weakness  or  mental  dullness  is  observed,  the  teeth  should  be 
inspected.  It  should  be  remembered  that  disease  of  the  ears,  disturb- 
ances of  vision  and  swelling  of  the  glands  of  the  neck  may  be  caused 
by  diseased  teeth. 

It  should  be  known  that  decay  of  the  teeth  is  caused  primarily  by 
the  fermentation  of  starchy  foods  and  sugars,  and  that  the  greatest 
factor  in  preventing  dental  caries  is  the  removal  of  food  particles  by 

191 


MEDICAL    INSPECTION    OF    SCHOOLS 

frequent  brushing.  Children  should  be  prevented  from  eating  crackers 
and  candy  between  meals,  and  when  possible  the  teeth  should  be  cleaned 
after  eating.  Inspection  of  the  teeth  by  a  dentist  should  be  made  at 
least  once  in  six  months. 

NERVOUS  TROUBLES  AND  MENTAL  DEFECTS 

Teachers  and  medical  inspectors  of  the  schools  should  investigate 
children  who  show  certain  physical  and  mental  symptoms.  Especially 
should  they  take  notice  of  the  presence  of  these  symptoms  in  a  child 
who  did  not  formerly  show  them.  The  most  important  of  these  are  the 
following: 

I. — Restlessness  and  inability  to  stand  or  sit  quietly,  in  a  previously 
quiet  child,  especially  if  to  this  is  added  irritability  of  temper  and  loss 
of  self-control,  as  shown  by  crying  for  trifles,  or  inability  to  keep  the 
attention  fixed. 

There  may  also  be  present  quick,  twitching  movements  of  the  mus- 
cles of  the  trunk,  face,  and  especially  of  the  hands,  fingers,  arms  or  legs. 
If  severe,  these  may  cause  the  child  to  drop  things,  render  its  work  awk- 
ward, or  interfere  with  buttoning  the  clothes,  writing  or  drawing.  Such 
children  are  often  scolded  for  being  inattentive  or  careless. 

These  symptoms  are  the  slighter  ones  of  chorea  (St.  Vitus'  dance). 
With  these  should  not  be  confounded  other  forms  of  twitching  of  mus- 
cles, such  as  the  blinking  of  the  eyelids,  the  slower  twitching  movements 
of  the  face  or  shoulders,  or  other  parts  of  the  body,  often  called  habit 
spasms,  which  may  be  due  to  defects  of  vision,  adenoid  growths  or  other 
reflex  causes.  These  latter  cases  do  not  usually  need  to  be  withdrawn 
from  school  work,  though  often  requiring  treatment;  while  the  former 
class  should  be  removed  from  school  at  once,  both  for  the  child's  sake 
and  to  prevent  an  epidemic  of  imitative  movements,  such  as  sometimes 
occurs. 

1 1 . — Another  class  of  symptoms  requiring  investigation  are  repeated 
faintings,  especially  if  the  child's  lips  become  blue;  attacks,  often  only 
momentary,  in  which  the  child  stares  fixedly  and  does  not  reply  to  ques- 
tions, or  in  which  he  suddenly  stops  speaking  or  whatever  he  is  doing,  and 
is  unaware  of  what  is  going  on  about  him.  These  lapses  of  consciousness 
may  be  accompanied  also  by  rolling  up  of  the  eyes,  drooling,  or  unusual 
movements  of  the  lips,  and  often  appear  like  a  "choking"  attack. 

Sudden  attacks  of  senseless  movements  of  various  sorts,  such  as 
twisting  and  pulling  at  the  clothes  or  handkerchief,  fumbling  aimlessly 
at  the  desk,  especially  if  there  is  no  recollection  afterwards  of  what  was 
done,  are  often  another  expression  of  the  same  conditions. 

192 


APPENDIX    I 

Such  attacks,  particularly  if  repeated  at  varying  intervals,  even 
when  not  accompanied  by  complete  loss  of  consciousness,  are  frequently 
as  characteristic  of  epilepsy  as  the  severe  convulsions. 

Epileptic  convulsions  usually  involve  the  entire  body  in  sharp 
jerking  movements,  with  blueness  of  the  face  or  lips,  complete  loss  of 
consciousness,  and  are  usually  followed  by  a  period  of  sleep  or  drowsi- 
ness, and  are  frequently  accompanied  by  frothing  at  the  mouth,  biting 
of  the  tongue,  and  occasionally  by  wetting  or  soiling  of  the  clothes. 

Another  class  of  convulsions  is  the  hysterical,  which  are  often 
difficult  to  distinguish.  The  hysterical  convulsion,  however,  differs  from 
the  epileptic  in  the  following  respects.  The  hysterical  patient  often  shouts, 
cries  or  raves,  not  only  previous  to  but  frequently  throughout  the  attack, 
and  is  often  able  to  reply  to  questions  during  the  convulsion.  The 
epileptic  gives  a  single  cry,  immediately  followed  by  unconsciousness 
and  the  spasm.  The  movements  in  the  hysterical  convulsion  are  often 
accompanied  by  bowing  of  the  body  backward,  and  very  frequently 
simulate  intentional  or  voluntary  movements,  such  as  tearing  the  hair, 
pulling  at  the  clothes,  and  such  things;  while  the  epileptic  movements 
are  characterized  by  their  jerking  or  twitching  character.  The  hysterical 
patient,  also,  in  place  of  a  convulsion,  may  strike  an  attitude,  such  as  of 
fear  or  entreaty,  often  accompanied  by  raving  or  singing.  This  again 
may  follow  the  convulsion,  taking  the  place  of,  and  strikingly  contrasted 
with  the  almost  invariable  sleep  of  the  epileptic,  which  is  almost  never 
seen  in  hysteria.  Hysterical  patients  if  they  fall  seldom  injure  them- 
selves by  the  fall,  as  epileptics  frequently  do.  Biting  the  tongue  almost 
invariably  indicates  an  epileptic  seizure,  as  does  wetting  or  soiling  the 
clothes  when  it  occurs. 

Cases  of  epilepsy,  whether  mild  or  severe,  require  treatment,  and 
advice  as  to  whether  they  should  be  removed  from  school.  Many  cases  do 
not  require  to  be  withdrawn  from  school,  and  are  benefited  by  its  discipline. 

III. — Excessive  nerve  fatigue,  which  is  shown  by  irritability  or 
sleeplessness,  may  indicate  a  neurasthenic  condition,  that  is,  a  threatened 
nervous  breakdown.  Such  symptoms  may  be  due  to  irregular  habits, 
want  of  proper  sleep,  lack  of  suitable  food,  poor  hygienic  conditions,  or 
simply  from  the  child  being  pushed  in  school  beyond  its  physical  or 
mental  capacity. 

Excessive  fear  or  morbid  ideas,  bashfulness,  undue  sensitiveness, 
causeless  fits  of  crying,  morbid  introspection  and  suspiciousness  may 
also  be  symptoms  of  a  neurasthenic  condition,  and  call  for  investiga- 
tion, and  for  the  teacher's  sympathy  and  winning  of  the  child's  confi- 
dence, to  prevent  developments  of  a  more  serious  nature. 

13  193 


MEDICAL    INSPECTION    OF    SCHOOLS 

This  nerve  fatigue  may  result  in  a  child  being  unable  for  the  time 
being  to  keep  up  in  its  work  in  school. 

Forgetfulness,  loss  of  interest  in  work  and  play,  desire  for  solitude, 
untidiness  in  dress  or  person,  and  like  changes  of  character,  are  some- 
times incidental  to  the  period  of  puberty. 

IV. — Mentally  defective  children  in  the  public  schools  exhibit  cer- 
tain common  characteristics.  The  essential  evidence  of  mental  defect 
is  that  the  child  is  persistently  unable  to  profit  by  the  ordinary  methods 
of  instruction,  as  shown  by  lack  of  progress  or  failure  of  promotion  through 
lack  of  capacity.  After  one,  two  or  three  years  in  school,  they  are  either 
not  able  to  read  at  all,  or  they  have  a  very  small  and  scanty  vocabulary. 
One  of  the  most  constant  and  striking  peculiarities  is  the  feebleness  of  the 
power  of  voluntary  attention.  The  child  is  unable  to  fix  his  attention 
upon  any  exercise  or  subject  for  any  length  of  time.  The  moment  his 
teacher's  direction  is  withdrawn,  his  attention  ceases. 

These  children  are  easily  fatigued  by  mental  effort,  and  lose  interest 
quickly.  They  are  not  observant.  They  are  often  markedly  back- 
ward in  number  work.  They  are  especially  backward  in  any  school 
exercise  requiring  judgment  and  reasoning  power.  They  may  excel 
in  memory  exercises.  They  usually  associate  and  play  with  children 
younger  than  themselves.  They  have  weak  will-power.  They  are 
easily  influenced  and  led  by  their  associates.  These  children  may  be 
dull  and  listless,  or  restless  and  excitable.  They  are  often  wilful  and 
disobedient,  and  liable  to  attacks  of  stubbornness  and  bad  temper.  The 
typical  "incorrigible"  of  the  primary  grades  often  is  a  mentally  defective 
child  of  the  excitable  type.  They  are  often  destructive.  They  may  be 
cruel  to  smaller  children.  They  are  often  precocious  sexually.  They 
may  have  untidy  personal  habits.  Certain  cases  with  only  slight  intel- 
lectual defect  show  marked  moral  deficiency. 

The  physical  inferiority  of  these  defective  children  is  often  plainly 
shown  by  the  general  appearance.  There  is  generally  some  evidence 
of  defect  in  the  figure,  face,  attitudes  or  movements.  They  seldom 
show  the  physical  grace  and  charm  of  normal  childhood.  The  teeth  are 
apt  to  be  discolored  and  to  decay  early. 

It  is  a  most  delicate  and  painful  task  to  tell  a  parent  that  his  child 
is  mentally  deficient.  This  duty  should  be  performed  with  the  greatest 
tact,  kindness  and  sympathy.  It  would  be  a  great  misfortune  for  the 
school  physician  and  teacher,  as  well  as  for  the  child,  to  designate  a 
pupil  as  feeble-minded  who  was  only  temporarily  backward. 

Temporary  backwardness  in  school  work  may  be  due  to  removable 
causes,  such  as  defective  vision,  impaired  hearing,  adenoid  growths  in 

194 


APPENDIX    I 

nose  or  throat,  or  as  the  result  of  unhappy  home  conditions,  irregular 
habits,  want  of  proper  sleep,  lack  of  suitable  food,  bad  hygienic  condi- 
tions, etc.  Great  care  must  always  be  used  in  order  not  to  confound 
cases  of  permanent  mental  deficiency  with  cases  of  temporary  back- 
wardness in  school  work,  due  to  the  causes  mentioned  above,  or  those 
described  under  the  head  of  excessive  nervous  fatigue. 

In  some  cases,  where  the  existence  of  mental  defect  is  in  doubt, 
accurate  information  is  usually  to  be  obtained  in  the  early  history  of 
the  child.  The  time  of  first  "taking  notice,"  the  time  of  recognition 
of  the  mother,  that  of  beginning  to  sit  up,  to  creep,  to  stand,  to  walk 
and  to  talk  should  be  learned.  Marked  delay  in  development  in  these 
respects  is  usually  found  in  all  pronounced  cases  of  mental  deficiency. 

It  may  be  found  useful  to  require  teachers  to  refer  at  stated  intervals 
to  the  medical  inspectors  for  examination  all  children  who,  without 
obvious  cause,  such  as  absence  or  ill  health,  show  themselves  unable  to 
keep  up  in  their  school  work,  who  are  unable  to  fix  their  attention,  or 
are  incorrigible, — though  it  does  not  follow  that  all  such  cases  have 
either  physical  or  mental  defects. 

SCHOOL  HYGIENE 

The  school  physician  should  notice  the  ventilating,  lighting  and 
heating  of  the  rooms,  and  the  location  of  the  source  of  water  supply  with 
reference  to  possible  pollution.  In  case  pollution  of  the  water  supply  is 
suspected,  application  should  be  made  to  the  State  Board  of  Health 
for  an  examination  of  the  water.  The  general  cleanliness  of  the  school- 
room is  of  importance,  and  the  admission  of  sunlight  when  possible  is 
desirable. 

The  Closets. — The  school  physician,  accompanied  by  the  janitor 
of  the  school,  should  inspect  the  toilet  rooms,  to  see  if  the  floors  are  clean 
and  dry,  that  the  bowls  of  the  closets  are  properly  emptied  and  kept 
clean.  (If  outhouses  are  used,  a  large  supply  of  earth  will  aid  in  keeping 
the  place  in  a  sanitary  condition.)  A  few  simple  directions  as  to  the 
cleanliness  of  the  room  should  be  posted  in  the  closets. 

Cups. — The  use  of  one  drinking  cup  for  a  number  of  children  is  to 
be  condemned,  as  tending  to  spread  the  infectious  diseases  from  child  to 
child.  The  so-called  hygienic  drinking  fountain,  now  in  more  or  less 
general  use  in  progressive  cities  and  towns,  is  to  be  recommended  where 
running  water  is  available.  If  there  is  no  running  water,  each  child 
should  use  his  own  cup. 


195 


MEDICAL    INSPECTION    OF    SCHOOLS 

SCHOOL  FURNITURE 

Any  proper  sort  of  school  furniture  should  furnish  a  seat  of  such 
height  that  the  feet  will  rest  easily  on  the  floor.  It  should  have  a  desk 
high  enough  not  to  touch  the  knees.  It  should  have  a  desk  low  enough 
for  the  arm  to  rest  on  comfortably  without  much  raising  of  the  elbow; 
not,  however,  so  low  that  the  scholar  must  bend  down  to  write  on  it. 

The  seat  should  be  near  enough  so  that  the  scholar  may  reach  the 
desk  to  write  on  it  without  leaning  forward  more  than  a  little,  and  without 
entirely  losing  the  support  of  the  backrest.  The  seat  should  not  be  so 
close  as  to  press  against  the  abdomen  nor  near  enough  to  interfere  with 
easy  rising  from  the  seat.  This  means  a  distance  of  ten  and  one-half 
to  fourteen  and  one-half  inches  from  the  edge  of  the  desk  to  the  seat 
back;  it  also  means  that  the  seat  must  not  project  under  the  desk  more 
than  an  inch  at  most. 

The  seat  should  have  a  backrest  that  will  support  the  "small  of 
the  back"  properly,  without  having  the  scholar  lean  back  excessively. 
Whether  it  also  supports  the  rest  of  the  back  or  not  is  of  small  conse- 
quence; support  of  the  back  carried  up  to  the  level  of  the  shoulder  blades 
is  likely  to  do  more  harm  than  good. 

These  are  given  as  the  minimum  requirements.  Whether  or  not 
regular  adjustable  furniture  is  in  use,  we  should  not  be  content  with 
less  than  the  accomplishment  in  one  way  or  another  of  these  primitive 
adjustments.  More  accurate  adjustment  is  desirable,  and  less  care  in 
adjusting  would  be  hard  to  justify,  in  the  light  of  our  present  knowledge 
of  the  results  of  faulty  attitude. 


196 


APPENDIX  II 

ANNUAL  REPORT  FOR  1910  OF  THE  CHIEF  MEDICAL 
OFFICER  OF  THE  BRITISH  BOARD  OF  EDUCATION 

The  following  pages  reproduce  the  table  of  contents  of  the 
Annual  Report  of  the  Chief  Medical  Officer  of  the  British  Board  of 
Education.  This  table  is  printed  to  show  the  range  of  subjects 
and  topics  treated  in  a  thorough  and  comprehensive  report  of  a 
system  of  medical  inspection.  The  report  from  which  this 
material  is  taken  is  probably  the  clearest,  most  thorough,  and 
most  complete  report  on  medical  inspection  that  has  yet  appeared. 
It  may  well  serve  as  a  model  for  medical  officers  reporting  on  work 
in  American  communities. 

CONTENTS 

Page 
I.  The  Administration  of  Medical  Inspection  by  the  Local  Educational 

Authorities 3 

Requirements  of  the  Code 4 

Schedule  of  Medical  Inspection 1 1 

Organization  of  School  Medical  Service 12 

The  School  Medical  Officer 14 

Qualifications  of  Medical  Officers 17 

School  Nurses 17 

Special  Inquiries '. 18 

Closure  of  and  Exclusion  from  School 20 

Medical  Inspection  of  Secondary  Schools 22 

II.  The  Physical  Condition  of  School  Children  as  revealed  by  Medical  In- 
spection    24 

Malnutrition 26 

Uncleanliness 33 

Defective  Vision 36 

Defective  Hearing 45 

Adenoids,  Enlarged  Tonsils  and  Glands 49 

Ringworm 56 

Miscellaneous  Conditions 62 

Addendum  on  Sanitation  of  School  Premises 65 

197 


MEDICAL   INSPECTION   OF    SCHOOLS 

Page 

III.  Tuberculosis  in  School  Children 69 

Findings  as  regards  Tuberculosis  from   the    Reports  of  School 

Medical  Officers 71 

Existing  Provision  for  the  Treatment  of  Tuberculous  Children ....  79 
Suggestions  for  the  Treatment  of  Tuberculous  Children  by  the 

Local  Education  Authority 85 

IV.  The  Proceeding  known  as  "  Following  Up" 96 

The  Part  played  by  the  School  Doctor  and  Parent 97 

The  Part  played  by  the  Teacher 98 

The  School  Nurse 100 

The  School  Attendance  Officer 103 

Voluntary  Agencies  and  Care  Committees 108 

The  Results  of  "  Following  Up" 108 

Addendum  on  the  Employment  of  School  Children 1 16 

V.  Action  taken  by  Local  Education  Authorities  in  respect  to  Medical 

Treatment 119 

Introduction 119 

The  Kind  of  Treatment  Necessary 119 

Treatment  by  Medical  Practitioners 121 

Modes  of  Treatment  Available 122 

1 .  Treatment  under  special  Acts  of  Parliament 123 

2.  Treatment  under  the  Poor  Law  (see  Section  VI) 123 

3.  Treatment  under  Section  13  of  the  Education  (Administra- 
tive Provisions)  Act,  1907 123 

Existing  Provision  for  Medical  Treatment  out  of  Public  Funds ....  126 

Employment  of  School  Nurses 126 

Provision  of  Spectacles 127 

Contributions  to  Hospitals 128 

The  London  County  Council  Hospital  Scheme 132 

VI.  Medical  Treatment  for  School  Children  under  the  Poor  Law 143 

VII.  School  Clinics 146 

The  Inspection  Clinic 146 

The  Treatment  Clinic 152 

Treatment  Clinics  now  established 155 

VIII.  Dental  Diseases  and  Dental  Treatment , 166 

Causation  of  Dental  Caries 171 

Diet  in  Relation  to  Dental  Disease 172 

The  Use  of  the  Toothbrush 1 73 

The  Treatment  of  Dental  Diseases 175 

School  Dentistry  in  Germany 177 

Existing  Arrangements  for  Dental  Treatment  in   England  and 

Wales 1 79 


,98 


APPENDIX    II 

(Page 
IX.  The  Special  Schools  for  Blind,  Deaf,  Physically  Defective  and  Epileptic 

Children 187 

Schools  for  the  Blind 188 

Schools  for  the  Deaf 193 

Schools  for  Physically  Defective  Children 201 

Schools  for  Epileptic  Children 203 

X.  Education  of  Feeble-minded  Children 206 

Adoption  of  the  Elementary  Education  (Defective  and  Epileptic 

Children)  Act,  1899 208 

Classification  of  Mentally  Defective  Children 209 

Educational  Provision  for  Mentally  Abnormal  Children 211 

The  After-care  of  the  Feeble-minded 214 

Conclusion 219 

X I .  Open-air  Education 22 1 

The  Open-air  Classroom 222 

Playground  Classes 223 

Country  Schools 225 

Open-air  Schools 226 

Premises 226 

Classification  of  Children  Admitted 227 

Cost  of  Open-air  Schools 228 

Provision  of  Meals 229 

Time-Table 229 

Results 230 

Permanency  of  Results 23 1 

XII.  The  Teaching  of  Hygiene  and  Physical  Training 233 

The  Teaching  of  Hygiene  in  the  Training  Colleges 233 

The  Teaching  of  Hygiene  in  Public  Elementary  Schools 236 

The  Teaching  of  Infant  Care  and  Management 238 

Physical  Training 242 

In  Training  Colleges 242 

In  Secondary  Schools 243 

In  Public  Elementary  Schools 243 

XIII.  Provision  of  Meals 245 

Introductory 245 

Historical  Note 246 

The  Act  of  1906 247 

Returns  from  Local  Educational  Authorities  for  1910 249 

Selection  of  Children  and  Duties  of  School  Medical  Officer 252 

Provision  of  Meals  during  Holidays 254 

Conclusion 256 


199 


MEDICAL    INSPECTION    OF    SCHOOLS 


APPENDICES 

Page 

A.  List  of  Medical  Officers,  etc 259 

B.  Prosecutions  by  Local  Education  Authorities 270 

C.  Memorandum  on  the  Teaching  of  Infant  Care  and  Management  in  Public 

Elementary  Schools  (Circular  758) 277 

D.  Memorandum  on  Physical  Training  in  Secondary  Schools  (Circular  779)  . .  289 

E.  Syllabus  of  Hygiene 299 

F.  The  Training  of  Teachers  of  the  Blind  and  the  Deaf 302 

G.  Statistical  Tables  Relating  to  the  Provision  of  Meals 303 


2OO 


BIBLIOGRAPHY 


BIBLIOGRAPHY 

BOOKS 

ALLEN,  WILLIAM  H.:  Civics  and  Health.  New  York,  Ginn  and  Com- 
pany, 1909.  411  pp.  $1.50. 

Contains  chapters  on  physical  welfare  of  school  children,  mouth- 
breathing,  eye-strain,  dental  sanitation,  and  departments  of  school 
hygiene. 

AYRES,  LEONARD  P.:     Medical     Inspection    Legislation.     New    York, 
Russell  Sage  Foundation,  191 1.     56  pp.     30  cents. 
Summary  of  legal  status  in  United  States. 

BERGER^TEIN,  LEO:  Schulhygiene.  Second  edition.  Leipzig,  B.  G. 
Teubner,  1910. 

CORNELL,  WALTER  S.:  Health  and  Medical  Inspection  of  School  Chil- 
dren. Philadelphia,  F.  A.  Davis  Company,  1912.  644  pp.  195 
illus.  $3.50. 

The  most  comprehensive  treatment  yet  published.  Based  on 
extended  experience.  Indispensable  in  the  library  of  the  school 
physician. 

CROWLEY,  RALPH  H.:  Needs,  Objects  and  Methods  of  the  Medical  In- 
spection of  Primary  Schools.  London,  J.  and  A.  Churchill,  1907. 
24  pp. 

CROWLEY,  RALPH  H.:  The  Hygiene  of  School  Life.  London,  Methuen 
and  Co.,  1910.  403  pp. 

Contains  practical  suggestions  for  dealing  with  problems  confront- 
ing local  boards  of  education,  medical  officers,  and  parents.  Chap- 
ters on  physical  condition  of  school  children,  special  groups,  school 
feeding,  baths,  exercise,  open-air  schools,  infectious  disease,  treat- 
ment and  school  buildings. 

DUFESTEL,  Louis:  Guide  pratique  du  medicin-inspecteur  des  ecoles. 
Preface  de  M.  le  Dr.  Le  Gendre;  avec  19  figures  dans  le  texte.  Paris, 
O.  Dion  et  fils,  1910.  236  pp. 

203 


MEDICAL    INSPECTION    OF    SCHOOLS 

HOAG,  ERNEST  B.:  The  Health  Index  of  Children.  San  Francisco, 
Whitaker,  Ray-Wiggin  Co.,  1910.  i88pp.  80  cents. 

A  manual  designed  to  show  teachers  and  parents  how  to  detect 
physical  defects  in  children  and  to  suggest  means  for  correcting  such 
defects  and  maintaining  health  afterwards. 

HOGARTH,  A.  H.:  Medical  Inspection  of  Schools.  London,  Henry 
Frowde,  Oxford  University  Press,  1909.  360  pp.  6s. 

KELYNACK,  T.  N.:  Medical  Examination  of  Schools  and  Scholars. 
London,  P.  S.  King  and  Son,  1910.  434  pp. 

Compilation  of  articles  on  the  different  divisions  of  work  and  the 
status  of  the  movement  in  different  countries.  Best  general  survey 
of  the  entire  field. 

MACKENZIE,  WM.  LESLIE:  The  Health  of  the  School  Child.  London, 
Methuen  and  Co.,  1906.  2s.  6d. 

Lectures  dealing  with  the  hygiene  of  school  life,  normal  growth 
during  school  ages,  and  medical  inspection  and  supervision  of  school 
children.  Gives  details  of  methods  of  medical  inspection  in  Wies- 
baden and  Nuremburg. 

MACKENZIE,  WM.  LESLIE,  AND  MATTHEW,  EDWIN:  The  Medical  In- 
spection of  School  Children.  Edinburgh  and  Glasgow,  William 
Hodge  and  Co.,  1904.  455  pp.  los.  6d.  net. 

The  most  extensive  and  thorough  treatise.  Technical  rather 
than  popular. 

SCHUBERT,  PAUL:  Das  Schularztwesen  in  Deutschland.  Bericht  iiber 
die  Ergebnisse  einer  Umfrage  bei  den  grosseren  Stadten  des  Deutschen 
Reiches.  Hamburg  und  Leipzig,  Verlag  von  Leopold  Voss,  1905. 
1 66  pp. 

STEVEN,  EDWARD  M.:  Medical  Supervision  in  Schools.  London, 
Bailliere,  Tindall  and  Cox,  1910.  268  pp. 

A  first  hand  description  of  the  workings  of  the  system  in  Great 
Britain,  Canada,  the  United  States,  Germany,  and  Switzerland. 

WOOD,  THOMAS  D.:  Health  and  Education.  The  Ninth  Yearbook  of 
the  National  Society  for  the  Study  of  Education.  Parti.  Chicago, 
The  University  of  Chicago  Press,  1910.  113  pp. 

Chapters  on  health  examinations,  school  sanitation,  hygiene  in- 
struction, and  physical  education.  Intended  for  the  use  of  teachers 
rather  than  the  specialist  in  school  hygiene  or  physical  education. 

204 


BIBLIOGRAPHY 

REPORTS,  AMERICAN 

BUREAU  OF  MUNICIPAL  RESEARCH:  A  Bureau  of  Child  Hygiene.  Re- 
port of  co-operative  studies  and  experiments  by  the  Department  qf 
Health  of  New  York  City  and  the  Bureau  of  Municipal  Research. 
New  York,  Bureau  of  Municipal  Research,  1908.  41  pp.  35  cents. 

Report  on  the  Division  of  Child  Hygiene,  Department  of  Health 
(New  York  City),  with  constructive  suggestions.  New  York  City, 
Bureau  of  Municipal  Research,  191 1.  66  pp. 

MASSACHUSETTS  BOARD  OF  EDUCATION:  Suggestions  to  Teachers  and 
School  Physicians  Regarding  Medical  Inspection.  Special  pamphlet. 
Boston,  1907. 

Medical  Inspection.  By  G.  H.  Martin.  72nd  Annual  Report,  1907- 
08,  pp.  87-109.  Boston,  Public  Document  No.  3,  1909. 

Medical  Inspection  in  the  Public  Schools  of  Massachusetts.  -By 
G.  H.  Martin.  74th  Annual  Report,  pp.  164-193.  Boston,  Public 
Document  No.  2,  1911. 

NATIONAL  SOCIETY  FOR  THE  STUDY  OF  EDUCATION:  The  Nurse  in 
Education.  The  Ninth  Year-book,  Part  II.  Chicago,  The  Uni- 
versity of  Chicago  Press,  1911.  76  pp. 

Chapters  on  The  Educational  Value  of  the  Nurse  in  the  Public 
School,  by  Isabel  M.  Stewart  and  M.  Adelaide  Nutting;  and  Profes- 
sional Training  of  Children's  Nurses  by  Mary  L.  Read. 

RUSSELL   SAGE    FOUNDATION:    What  American   Cities   are    Doing  for 
the  Health  of  School  Children.     Bulletin,  Dept.  of  Child  Hygiene, 
New  York,  191 1.    24  pp.     15  cents. 
Summary  of  conditions  in  1,032  American  cities. 

REPORTS,  FOREIGN 

BOARD  OF  EDUCATION  (BRITISH):  Annual  Report  for  1910  of  the  Chief 
Medical  Officer.  London,  Wyman  and  Sons,  Fetter  Lane  E.  C. 
1911.  313  pp. 

BRADFORD  (ENGLAND)  EDUCATION  COMMITTEE:  Report  of  the  School 
Medical  Officer  (Lewis  William,  M.D.)  for  year  ending  December 
31,  1909.  1910.  117  pp. 

DUNFERMLINE,  SCOTLAND:  Fourth  Annual  Report  on  the  Medical  In- 
spection of  School  Children  in  Dunfermline.  By  J.  C.  Bridge.  Car- 
negie Institute,  1909. 

205 


MEDICAL    INSPECTION    OF    SCHOOLS 

NEW  SOUTH  WALES:  Department  of  Public  Instruction.  Report  upon 
the  Physical  Condition  of  Children  Attending  Public  Schools  in 
New  South  Wales  (with  special  reference  to  height,  weight,  and 
vision),  based  upon  statistics  obtained  as  a  result  of  the  introduction 
of  a  scheme  of  medical  inspection  of  public  school  children,  1907-08, 
with  anthropometric  tables  and  diagrams.  Sydney,  Wm.  A.  Gul- 
lick,  Government  Printer,  1908.  66  pp. 

Report  upon  the  Physical  Condition  of  Children  Attending  Public 
Schools  in  New  South  Wales,  based  upon  observations  made  in  con- 
nection with  the  medical  inspection  of  public  school  children,  1908-09, 
with  anthropometric  tables  and  diagrams.  Sydney,  Wm.  A.  Gul- 
lick,  Government  Printer,  1910.  35  pp. 

LONDON  COUNTY  COUNCIL:     School    Dentistry    in    Germany.     Report 
of  the  Education  Officer  presented   to  the  Education  Committee, 
June  22,  1910.     London,  Southwood,  Smith  and  Co.,  1910.     10  pp. 
Report  of  the  Medical  Officer  (Education)  for  twelve  months  end- 
ing Dec.  31,  1909.     London,  Southwood,  Smith  and  Co.,  1910.  96  pp. 

TASMANIA:  Report  on  the  Work  of  the  Medical  Branch.  J.  S.  C.  Elk- 
ington,  M.D.,  Chief  Health  Officer.  Hobart,  John  Vail,  Government 
Printer,  1908.  15  pp. 

BIBLIOGRAPHIES 

TEACHERS  COLLEGE,  COLUMBIA  UNIVERSITY:  A  Bibliography  on  Edu- 
cational Hygiene  and  Physical  Education.  By  Dr.  Thomas  D. 
Wood  and  Mary  Reesor.  New  York  City,  Teachers  College,  1911. 
41  pp.  20  cents. 

UNITED  STATES  BUREAU  OF  EDUCATION:  Bibliography  of  Child  Study 
for  the  Years  1908-1909.  By  Louis  N.  Wilson.  Washington,  D.  C., 
Bureau  of  Education  Bulletin  No.  11,1911.  84  pp. 

Bibliography  of  Education  for  1909-10.  Washington,  D.  C., 
Bureau  of  Education  Bulletin  No.  10,  191 1.  166  pp. 

Contains  sections  on  ventilation  and  lighting,  cleaning  and  dis- 
infecting of  school  rooms,  school  hygiene,  medical  inspection,  con- 
tagious diseases,  feeding  of  school  children,  open-air  schools,  eyes, 
ears,  and  teeth. 


206 


INDEX 


INDEX 


ADENOIDS:  among  children  promoted 
and  not  promoted  in  South  Man- 
chester, 155;  among  retarded 
children  in  Elmira,  156;  and 
associated  defects,  58;  and  school 
progress  in  New  York,  158-162; 
classed  with  cases  of  defective 
breathing,  39;  handicap  in  school 
work,  3,  4,  162;  treated  in  English 
communities,  99 ;  treated  in  Harris- 
burg,  94;  treated  in  Newark,  N.  J., 
93;  treated  in  Summit,  N.  J.,  95 

ADMINISTRATION:  of  dental  clinics  in 
Germany,  118,  in  United  States, 
122;  of  medical  inspection  in 
cities  of  the  United  States,  143-151 ; 
of  medical  inspection  in  England, 
176;  placed  in  hands  of  school 
authorities  by  most  state  laws, 
164;  provision  regarding,  which 
new  laws  should  contain,  171 

AGE  OF  CHILDREN:  the  important 
factor  in  physical  defects,  157, 162 

ALBERTA,  Canada:  medical  inspection 
in,  12 

AMERICA  :  frequency  of  examinations  in, 
41;  salaries  of  school  physicians 
and  nurses  in,  compared  with 
those  in  England,  103,  109,  no. 
See  also  United  States 

AMERICAN  SCHOOL  HYGIENE  ASSOCIA- 
TION: data  regarding  nurses'  work 
presented  to,  66 

AMERICANS:  teeth  and  jaws  of,  116 

ANDOVER,  Mass.:  report  on  weight  and 
teeth  of  school  children  in,  116 

ANEMIA:  among  retarded  children  in 
Elmira,  156 

ANEMIC  CHILDREN:  open  air  schools 
for,  98 

ANGLESEY,  England:  treatments  in,  99 


ANN  ARBOR,  Michigan:  woman  denta 
inspector  in,  122, 127 

ARGENTINE  REPUBLIC:  medical  inspec- 
tion in,  12 

ATTENDANCE,  SCHOOL:  and  retardation, 
154;  authority  to  compel,  carries 
with  it  duties,  4;  figures  taken 
from  United  States  Commissioner 
of  Education's  report,  103;  in 
cities  of  United  States,  104-107 

AUSTRALIA  AND  TASMANIA:  medical 
inspection  in,  12 

AUSTRIA:  dental  clinics  in,  120;  medi- 
cal inspection  in,  1 1 

AUTHORITIES  CONTROLLING  MEDICAL 
INSPECTION.  See  Medical  Inspec- 
tion 

BACKWARD  CHILD:  lessons  taught  by, 
will  make  a  better  race,  6 

"BACKWARD  CHILDREN":  term  added 
to  vocabulary  of  school  men,  3 

BACKWARD  PUPILS.    See  Retarded 

BANNON,  DR.:  appointed  by  school 
committee  of  Lawrence,  149 

BARLOW,  PETER  T.,  and  his  friends: 
dental  clinic  given  by,  121 

BECKENHAM,  England:    treatments  in, 

99 
BELGIUM:  medical  inspection  in,  n 

BERKELEY,  California:  consultations 
with  medical  director  in,  77,  79; 
record  of  physical  examinations 
usedin,  53,  56,  57 

BERLIN:  dental  work  in,  126 

BIRMINGHAM,  Alabama:  post  card 
notification  used  in,  73,  74 

BLACKBURN,  England:  treatments  in, 
99 


14 


209 


INDEX 


BLAKE,  CLARENCE  JOHN:  opinion  on 
teachers'  ability  to  test  hearing,  45 

BLISS,  D.  C.:  study  of  defects  among 
retarded  children  by,  155 

BOARD  OF  EDUCATION.    See  Education 
BOARDS  OF  HEALTH.    See  Health 

BODILY  STRUCTURE:  defects  of,  37.  See 
also  Orthopedic  Defects 

BOSTON:  follow-up  system  not  well 
developed  in,  42;  medical  inspec- 
tion in,  i,  13;  number  of  pupils 
examined  in  1912,  41,  42;  plan  for 
dental  clinic  in,  123;  results  of 
physical  examinations  in,  38,  39; 
superintendent  of  schools  in, 
quoted,  146 

BREATHING,  DEFECTIVE:  among  school 
children  in  New  York,  40;  and 
school  progress  in  New  York,  158- 
162;  cases  classed  with  adenoids, 
39;  treated  in  Harrisburg,  94; 
treated  in  New  York,  92 

BREATHING,  NASAL:  prevented  by  en- 
larged tonsils  and  adenoids,  4 

BRITISH  BOARD  OF  EDUCATION:  chief 
medical  officer,  quoted,  98;  in- 
spections provided  for  by,  41; 
memorandum  of,  quoted,  10,  75, 
175,176 

BRITISH  SOLDIERS:  jaws  of,  compared 
with  those  of  Roman  soldiers,  116 

BROCKTON,  Massachusetts:  forms  used 
in,  22,  23 

BRUSSELS:   medical  inspection  in,  n 

BRYAN,  JAMES  E.:  study  of  school 
progress  and  physical  condition  by, 
154 

BUILDINGS,  SCHOOL:  inspection  of, 
under  state  laws,  165;  provision 
for  inspection  of,  in  new  laws,  172 

BULGARIA:  medical  inspection  in,  12 

BULLETINS  ON  PHYSICAL  DEFECTS,  80, 
82,  129, 131,  132 

BUREAU  OF  CHILD  AND  ANIMAL  PRO- 
TECTION, Colorado  State,  83-85 


CAIRO:  medical  inspection  in,  12 

CALIFORNIA:  abstract  of  medical  in- 
spection law,  167;  and  New  Jersey 
cities  lead  in  salaries  to  school 
physicians  and  nurses,  103;  cities, 
health  pamphlets  used  in,  80,  82, 
129,132 

CAMBRIDGE,  England:  dental  clinic 
in,  119 

CAMDEN:  study  of  retarded  children 
in,  154 

CANADA:  school  physicians  appointed 
in,  12 

CARDIAC  DISEASE:  among  school  chil- 
dren in  New  York,  40;  treated  in 
Harrisburg,  Penn.,  94;  treated 
in  New  York,  92.  See  also  Heart 

CENSUS  BUREAU,  UNITED  STATES: 
grouping  of  states  by,  14 

CHARITY  ORGANIZATION  SOCIETY  of 
READING:  investigates  for  dental 
clinic,  122 

CHARLOTTENBURG:  school  nurses  in,  10; 
dental  work  in,  126 

CHEST  MEASUREMENTS:  taken  in  Wies- 
baden, 9 

CHICAGO:  exclusions  for  contagious 
diseases  in,  32,  33;  medical  in- 
spection in,  13;  number  of  pupils 
examined  in,  1910,  41;  record  of 
physical  examinations  used  in,  53, 
54;  records  of  contagious  disease 
inspection  used  in,  24,  25,  26;  re- 
sults of  physical  examinations,  38 

CHICKEN-POX:   exclusions  for,  30-33 
CHIHUAHUA:  medical  inspection  in,  12 

CHILD  AND  ANIMAL  PROTECTION,  Col- 
orado State  Bureau  of,  83-85 

CHILD  HYGIENE,  DIVISION  OF:  of  New 
York  Department  of  Health,  91 

CHILD.  SCHOOL:  has  right  to  claim 
protection,  4 

CHILDREN:  defects  and  school  progress, 
152-163;  number  per  school  nurse , 
68;  older,  have  fewer  defects, 
162;  payments  according  to  num- 
ber examined,  in  Germany,  9;  pro- 
portions found  defective,  in  cities 
of  United  States,  37-39;  treated 


210 


INDEX 


CHILDREN  (Continued)' 

for  defects,  in  three  cities  of  United 
States,  96.  See  also  Pupils;  De- 
fects 

CHILDREN'S  AID  SOCIETY,  New  York 
City:  dental  clinics  of ,  121;  direc- 
tions issued  by,  129;  sells  tooth 
brushes,  129 

CHILE:  medical  inspection  in,  12 
CHINESE:  teeth  of,  116 

CHOREA:  among  school  children  in  New 
York,  40;  treated  in  Harrisburg, 
Pa.,  94;  treated  in  New  York,  92 

CINCINNATI,  Ohio:  dental  work  in,  88, 
123;  exclusions  and  school  mem- 
bership in,  33 

CLERICAL  ASSISTANCE  to  medical  inspec- 
tors, no,  in 

CLEVELAND,  Ohio:  dental  clinic  in,  121; 
exclusions  and  school  membership 
in,  33;  number  of  pupils  examined 
in,  1910-11,  41;  results  of  physical 
examinations  in,  38;  school  clinic 
for  eyes  in,  88;  superintendent  of 
schools  in,  quoted,  147 

CLINIC,  EYE:  in  Cleveland,  88 

CLINICS,  DENTAL:  cost  of  supplies  and 
equipment  for,  125;  established  by 
dental  associations,  18;  established 
in  Rochester,  N.  Y.,  114;  in  En- 
gland, 119,  120;  in  Germany,  117, 
118,  126;  law  regarding,  in  New 
Jersey,  1 24;  per  capita  cost  for  treat- 
ment in,  125-127;  plan  for,  in  Bos- 
ton, 123;  salaries  of  dentists  in,  127 

CLINICS:  parents'  consent  to  treatment 
of  children  at,  73;  school  and 
hospital,  86-88;  subsidies  to,  in 
England,  87 

COLLINS,  EDWIN:  scholarship  and  con- 
dition of  teeth  reported  on  by,  116 

COLMAR:   dental  work  in,  126 

COLOGNE:  dental  clinic  in,  cost  of,  117; 
dental  work  in,  126 

COLORADO:  abstract  of  medical  inspec- 
tion law,  167;  compulsory  action 
against  parents  in,  83-85;  vision 
and  hearing  tests  prescribed  in,  101 


COMMISSIONER  OF  EDUCATION:  figures 
from  reports  of,  42,  103 

COMPULSORY  ACTION  AGAINST  PAR- 
ENTS: in  England,  86;  in  United 
States,  83-86 

COMPULSORY  EDUCATION  and  compul- 
sory disease,  i,  2,  3 

CONJUNCTIVITIS:   exclusions  for,  32,  33 

CONNECTICUT:  abstract  of  medical  in- 
spection law,  167;  medical  inspec- 
tion legislation  in,  4,  13,  164; 
vision  tests,  cost,  102;  vision 
tests,  results,  52 

CONSULTATIONS  WITH  SCHOOL  PHYSI- 
CIANS: in  cities  of  United  States, 
76-79 

CONTAGIOUS  DISEASES:  cost  of  inspec- 
tion for,  101,  112;  exclusions  for, 
in  cities  of  United  States,  32,  33; 
exclusions  for,  in  New  York,  63,  65; 
exclusions  for,  reduced  by  school 
nurses'  work,  63,  65;  for  which 
children  are  excluded  from  school, 
30,  31;  inspection,  a  small  part 
of  medical  inspection,  143,  144; 
inspection  in  Germany,  9;  inspec- 
tion in  Paris,  8;  inspection  in 
United  States,  19,  20,  21-34;  in- 
spection in  Wiesbaden,  9;  inspec- 
tion placed  in  physicians'  hands  by 
state  laws,  164;  instructions  regard- 
ing symptoms  of,  30;  medical 
inspection  due  to,  i,  13,  21; 
provision  regarding,  which  new 
laws  should  contain,  172.  See  also 
Exclusions;  Epidemics 

COPENHAGEN:  medical  inspection  in,  u 

CORNELL,  WALTER  S.:  report  on  defec- 
tive children,  152 

COST:  annual  per  capita  for  medical 
inspection,  102-110;  clerical  assist- 
ance, no-in;  dental  clinics  in 
Germany,  117,  126;  dental  treat- 
ment, per  capita,  125-127;  inspec- 
tion for  contagious  disease,  101, 
112;  physical  examinations  in 
United  States,  43,  101-110;  sup- 
plies and  equipment  for  dental 
clinics,  125;  vision  and  hearing 
tests  by  teachers,  101,  102, 112 


211 


INDEX 


DARLINGTON,  Eng.:    treatments  in,  99 
DARMSTADT:  dental  work  in,  126 

DEAFNESS:  as  a  handicap  in  school 
work,  4.  See  also  Hearing;  Ear 

DEFECTIVE  CHILD:  lessons  taught  by, 
will  result  in  a  better  race,  6 

DEFECTIVE  CHILDREN.  See  Children: 
Pupils;  Defects 

DEFECTS  OF  EYE  AND  EAR:  treatments 
following  discovery  of,  by  teachers, 
97.  See  Eye;  Ear;  Vision;  Hearing 

DEFECTS,  PHYSICAL:  and  school  prog- 
ress, 152-163;  common  among 
school  children,  35, 37,  39;  decrease 
with  age,  157,  162;  found  among 
children  in  New  York,  40;  found 
among  children  in  nine  cities,  38; 
records  of  combinations  of,  58-61; 
treated  by  private  practitioners  and 
institutions,  New  York,  96,  St. 
Louis,  97;  treated  in  England,  98- 
100 ;  treated  in  Harrisburg,  Penn., 
94;  treated  in  Newark,  N.  J.,  93; 
treated  in  New  York  City,  91,  92; 
treated  in  Pasadena,  Cal.,  94;  treat- 
ments in  American  cities  compared, 
95-97;  treatments  in  United  States 
and  England  compared,  100 

DENMARK:  medical  inspection  in,  n 

DENTAL  ASSOCIATION,  Rochester,  N.  Y. : 
secured  lecturer  for  children,  1 28 

DENTAL  ASSOCIATIONS:  clinics  estab- 
lished by,  1 8, 122 

DENTAL  CLINICS.    See  Clinics 
DENTAL  HYGIENE:  education,  127-133 

DENTAL  WORK  FOR  SCHOOL  CHILDREN: 
in  England  and  other  countries, 
119-120;  in  Germany,  10, 117-119, 
126;  in  United  States,  18,  19,  120- 
124 

DENTISTS,  SCHOOL:  early  work  of,  in 
Belgium,  u;  employed  in  United 
States,  1 8,  19,  121,  122;  salaries 
of,  in  Germany,  England  and 
United  States,  127;  state  officers 
in  Strassburg,  117 

DERBY,  C.  B.,  England:  treatments 
in,  99 


DETROIT,     Michigan:     exclusions    for 
.     contagious  diseases  in,  32,  33 

DEVONSHIRE,  Eng.:   treatments  in,  99 
DINSBERG:  dental  work  in,  126 
DIPHTHERIA:  exclusions  for,  30-33 

DISEASE:  unbusinesslike  not  to  count 
cost  of,  3.  See  also  Contagious 
Diseases 

DISTRICT  OF  COLUMBIA:  regulations  on 
medical  inspection  in,  13,  144,  164, 
167 

DORTMUND:  dental  work  in,  126 
DRESDEN:  medical  inspection  in,  8 

DUNFERMLINE,  Scotland:  dental  con- 
ditions among  children  in,  115; 
dental  work  in,  120 


EAR  DISEASES:  treated  in  English 
communities,  99 

EAR  TROUBLES:  health  pamphlet  on, 
80 

EARS,  DEFECTIVE:  found  among  chil- 
dren in  different  cities,  38;  treated 
in  English  school  clinics,  87; 
treated  in  Lowell  and  Somerville, 
Mass.,  97;  treated  in  Pasadena, 
94.  See  also  Hearing 

EDUCATION:  compulsory,  and  compul- 
sory disease,  i,  2;  without  health 
useless,  4 

EDUCATION  ACT  OF  1907  for  England 
and  Wales,  10 

EDUCATION  ACT  OF  1908  in  Scotland,  10 

EDUCATION  AUTHORITIES:  co-opera- 
tion needed  in  physical  examina- 
tions, 53;  execution  of  medical 
inspection  law  in  England  laid  on, 
176 

EDUCATION,  BOARDS  OF:  medical  in- 
spection under,  143-150 

EDUCATION,  ENGLISH  BOARD  OF:  chief 
medical  officer  quoted,  98;  inspec- 
tions provided  for  by,  41 ;  memo- 
randum on  medical  inspection, 
quoted,  10,  75,  175,  176 

EDUCATION,  MASSACHUSETTS  BOARD  OF: 
directions  issued  by,  45,  47 


212 


INDEX 


EDUCATION,  UNITED  STATES  COMMIS- 
SIONER OF:  enrollment  figures 
from  report  of,  42;  attendance 
figures  taken  from  reports  of,  103 

EGYPT:   medical  inspection  in,  12 

ELMIRA,  New  York:  dental  conditions 
among  school  children  in,  115; 
dental  work  in,  88,  123;  no  charges 
for  treatment  in  dental  infirmary, 
126;  running  expenses  of  dental 
clinics  in,  125;  study  of  defects 
among  retarded  children  in,  155, 
156 

ELY,  ISLE  or:  treatments  in,  99 

ENFORCEMENT:  provision  for,  which 
new  laws  should  contain,  172.  See 
also  Compulsory  Action 

ENGLAND:  children  per  school  dentist 
in,  126;  dental  work  for  school 
children  in,  114,  119;  fines  imposed 
on  parents  of  school  children  in, 
86;  frequency  of  examinations  re- 
quired by  board  of  education  in,  41 ; 
medical  inspection  in,  10;  pioneer 
in  employment  of  school  nurses, 
ii ;  presence  of  parents  at  ex- 
aminations of  children  in,  73,  75, 
76;  salaries  of  school  physicians  in, 
109-110;  treatments  in,  98,  99, 100 

ENROLLMENT:  and  exclusions,  in  eight 
cities,  33;  and  physical  examina- 
tions, in  nine  cities,  41;  figures, 
from  report  of  United  States  Com- 
missioner of  Education,  34,  42 

EPIDEMICS:  among  school  children  in 
Boston,  13;  checked  by  medical 
inspection,  2,  34.  See  also  Con- 
tagious Diseases;  Exclusions 

EQUIPMENT:  and  supplies  for  dental 
clinics,  125;  school  nurses,  112; 
school  physicians,  in 

ESKIMOS:  teeth  of,  116 

ESSEX,  England:   treatments  in,  99 

EUROPEANS:  teeth  of,  116 

EVERETT,  Massachusetts:  directions 
and  prescriptions  used  in,  27-29 

EXAMINATIONS,  PHYSICAL:  by  physi- 
cians, in  United  States,  19,  20; 
cities  conducting,  by  groups  of 


EXAMINATIONS,  PHYSICAL  (Continued] 
states,  36;  conduct  of,  37;  cost  of, 
43,  101-110;  forms  needed  in  con- 
nection with,  52,  58;  frequency  of, 
40,  41 ;  in  Australia  and  Tasmania, 
12;  in  Great  Britain,  10;  in  Paris, 
7;  medical  inspection  extended  to 
include,  3;  need  of,  summarized, 
61;  new  laws  should  provide  for, 
172;  placed  in  hands  of  school 
physicians  by  state  laws,  164; 
presence  of  parents  at,  73,  75,  76; 
results  of,  in  cities  of  United  States, 
38,39;  results  of ,  in  New  York,  40; 
time  required  for,  43;  theory  and 
origin  of,  35;  Wiesbaden  system,  9 

EXAMINATIONS,  VISION  AND  HEARING. 
See  Vision  and  Hearing  Tests 

EXCEPTIONAL  CHILDREN:  special  classes 
for,  in  Germany,  10;  use  of  term,  3 

EXCLUSION  NOTICES  to  parents,  and 
their  use,  21,  22,  24-27 

EXCLUSIONS:  diseases  for  which  chil- 
dren are  excluded,  30,  31;  in 
various  cities  of  United  States, 
32-34,  143,  144;  in  New  York 
City,  63,  65;  reduced  by  school 
nurses'  work,  63 , 65 .  See  also  Con- 
tagious Diseases;  Epidemics 

EXEMPT  AND  NON-EXEMPT  CHILDREN  in 
Philadelphia:  defectiveness among, 
152,  153 

EYE  AND  EAR  EXAMINATIONS.  See 
Vision  and  Hearing  Tests 

EYE  CLINIC:  in  Cleveland,  88 

EYES,  DEFECTIVE:  among  children  in 
different  cities,  38;  among  chil- 
dren promoted  and  not  promoted 
in  South  Manchester,  155;  one 
of  four  commonest  classes  of  de- 
fects, 37,  39;  treated  in  English 
communities,  87,  99;  treated  in 
Lowell  and  Somerville,  97 ;  treated 
in  Pasadena,  94.  See  also  Vision; 
Eyesight 

EYESIGHT:  directions  for  testing  in 
Massachusetts,  45,  47;  health 
pamphlet  regarding,  82;  Snellen 
chart  for  testing,  49.  See  also 
Vision 


213 


INDEX 


FEEDING,  SCHOOL:  in  Germany,  10 

FOLLOW-UP  SYSTEM:  not  so  well  de- 
veloped in  Boston  as  in  New  York, 
42 

FOLLOW-UP  VISITS:  by  nurse,  to  secure 
action,  76 

FORMS:  used  in  medical  inspection. 
See  Records;  List  of  Forms,  p.  xix 

FORSYTH,  THOMAS  A. :  gift  of,  to  estab- 
lish dental  clinic  in  Boston,  124 

FRANCE:  dental  clinics  in,  120;  medical 
inspection  in,  7-8 

FRANKFORT-ON-THE-MAIN:  medical  in- 
spection in,  8 


GERMANY:  dental  work  for  school  chil- 
dren in,  114,  117-118,  126;  fre- 
quency of  physical  examinations, 
40,  41 ;  medical  inspection  in,  8-10; 
presence  of  parents  at  examina- 
tions of  children  in,  73,  76;  school 
nurses  and  movements  allied  to 
medical  inspection  in,  10 

GLANDS,  ENLARGED:  among  children 
in  different  cities,  38;  among  re- 
tarded children  in  Elmira,  156; 
and  school  progress  in  New  York, 
158-162;  cities  which  do  not  re- 
port, 39;  treated  in  Harrisburg, 
Perm.,  94 

GLASSES:  obtained  by  school  children 
in  Newark,  N.  J.,  93;  obtained  by 
school  children  in  New  York,  92, 
96 

GRADES,  SCHOOL:  completed  by  chil- 
dren with  and  without  defects, 
159,  160;  years  required  to  com- 
plete, by  defective  children,  161, 162 

GREAT  BRITAIN:  medical  inspection  in, 
10;  co-operation  between  school 
authorities  and  hospitals  in,  86, 
87.  See  also  Englaiid;  Education, 
English  Board  of;  Legislation 

GUANAJUATO  :  medical  inspection  in,  1 2 

GUILFORD,  ENGLAND:  salaries  of  medi- 
cal officers  in,  no 


HALIFAX:  medical  inspection  in,  12 


HAMBURG:    dental  work  in,  117,  118; 

per  capita  cost  of  dental  treatment, 

125 
HARRINGTON,  THOMAS  F.:  quoted,  146 

HARRISBURG,  Pennsylvania:  physical 
defects  treated  in,  94 

HAVERKELL,  Massachusetts:  superin- 
tendent of  schools,  quoted,  149 

HEALTH  AUTHORITIES:  co-operation 
with,  in  medical  inspection  urged 
by  English  board  of  education,  176 

HEALTH,  BAD:  among  normal  and  re- 
tarded children  in  Camden,  154 

HEALTH,  BOARD  OF:  Massachusetts, 
directions  prepared  by,  on  sight 
and  hearing  tests,  45,  47;  New 
York  City,  division  of  child  hy- 
giene, 91 ;  New  York  City,  supplies 
nurse  to  dental  clinic,  121;  New 
York  State,  dentists  employed  by, 
to  lecture,  127;  Virginia,  bulletin 
on  teeth  issued  by,  127 

HEALTH,  BOARDS  OF:  can  conduct  con- 
tagious disease  examinations,  53; 
medical  inspection  under,  143-150; 
regulations  of,  on  medical  inspec- 
tion, 13;  resolutions  adopted  at 
conference  of,  1 73 ;  salaries  of  medi- 
cal inspectors  under,  103 

HEALTH  PAMPHLETS:  by  Dr.  Ernest  B. 
Hoag,  80,  82,  132 

HEARING,  DEFECTIVE:  among  exempt 
and  non-exempt  children  in  Phila- 
delphia, 153;  among  normal  and 
retarded  children  in  Camden,  154; 
among  retarded  children  in  Elmira, 
156;  among  school  children  in 
New  York,  40;  effect  on  school 
work,  35;  treated  in  English  com- 
munities, 99;  treated  in  Harris- 
burg,  94;  treated  in  New  York,  92; 
treated  in  Summit,  95.  See  Ears, 
Defective 

HEARING  TESTS:  by  teachers  and  phy- 
sicians in  United  States,  19,  20; 
directions  for  making,  issued  in 
Massachusetts,  46;  made  by  phy- 
sicians and  teachers  in  cities  of 
United  States,  51,  52;  new  laws 
should  provide  for,  172;  opinions 
of  specialists  as  to  teachers'  ability 


214 


INDEX 


HEARING  TESTS  (Continued) 

to  make,  44,  45;  provision  for,  in 
state  laws,  165;  section  of  Massa- 
chusetts law  on,  179.  See  also 
Vision  and  Hearing  Tests 

HEART:  examination  of,  9,  37.  See 
Cardiac  Disease 

HEIGHT  AND  WEIGHT:  records  futile, 
37;  records  in  Paris,  8;  records  in 
Wiesbaden  system,  9 

HENIE,  DR.  C.:  dental  conditions 
among  school  children  in  Norway 
found  by,  115 

HERNIA:  examination  for,  in  Wiesba- 
den, 9 

HESSE-DARMSTADT:  medical  inspection 
in,  9 

HOAG,  ERNEST  BRYANT:  author  of 
Health  Index  of  Children,  80; 
health  pamphlets  by,  reproduced, 
80,  82,  132 

HOLMES,  GEORGE  J.:  equipment  for 
school  physicians  and  nurses 
recommended  by,  111,112;  quoted, 
87 

HOSPITAL  CLINICS,  86,  87 

HOSPITALS:  parents'  consent  to  treat- 
ment of  children  at,  73;  subsidies 
to,  in  England,  87 

HUNGARY:  dental  conditions  among 
school  children  in,  114;  medical 
inspection  in,  1 2 

HYGIENE,  DENTAL:  education  in,  127- 
133 


IMPETIGO  CONTAGIOSA:  directions  and 
prescription  for,  27,  28;  exclusions 
for,  30,  32,  33 

INDIANA:  abstract  of  medical  inspec- 
tion law  in,  167 ;  vision  and  hearing 
tests  prescribed  in,  101 

INDIANS,  AMERICAN:  teeth  of,  116 

INFIRMARY,  DENTAL:  in  Boston,  For- 
syth  gift  to  establish,  124.  See 
also  Clinics,  Dental 


INSPECTION:  for  contagious  disease, 
cost  of,  101,  112;  of  teachers,  jani- 
tors, and  buildings  under  state 
laws,  164-165,  172;  intervals  at 
which  to  take  place  in  England  and 
the  United  States,  40,  41;  mini- 
mum per  capita  cost  for  efficient, 
103  See  also  Medical  Inspection 

INSPECTORS,  MEDICAL:  corps  appointed 
in  New  York,  13;  results  obtained 
by,  with  and  without  aid  of  nurses, 
66,  67;  salaries  of,  102-110.  See 
also  Physicians,  School 

INSTITUTIONS:  treatments  by,  New 
York,  96;  treatments  by,  St.  Louis, 
97 

IRELAND:  medical  inspection  in,  10 


JANITORS:    inspection  of,  under  state 
laws,  165,  172 

JAPAN:   medical  inspection  compulsory 
and  universal  in,  1 2 

JAW,   width   of:    among   ancient   and 
modern  peoples,  116 

JESSEN,  DR.:    dental  clinic  established 
by,  in  Strassburg,  117 

JOHNSON,  GEORGE  F. :  weight  and  con- 
dition of  teeth  reported  on  by,  116 

JUVENAL:    on  the  sound  mind  in  the 
sound  body,  6 

KENT,  England:  treatments  in,  99 

KNOWLES,  WM.  F.:    opinion  on  teach- 
ers' ability  to  test  hearing,  45 


LAWRENCE,  Massachusetts:  conflict 
between  health  and  educational 
authorities  in,  148 

LAWS:  compulsory  education,  2 

LAWS,  MEDICAL  INSPECTION:  abstract 
of,  in  United  States,  167-171; 
authorities  with  which  administra- 
tion placed,  144;  early,  in  United 
States,  13;  history  and  present 
status  of,  164;  mandatory  pref- 
erable to  permissive,  4,  5 ;  of  Eng- 
land, quoted,  174;  Massachu- 
setts, text  of,  178;  points  on  which 


215 


INDEX 


LAWS,     MEDICAL    INSPECTION    (Con- 
tinued) 

there  is  substantial  agreement 
among,  164,  165;  principal  fea- 
tures of,  1 66;  provisions  which 
should  be  included  in,  171,  172; 
similarities  between  those  of  Eng- 
land and  Massachusetts,  179,  180. 
See  also  names  of  states  and  coun- 
tries; Education  Act;  Legislation; 
Regulations 

LEGAL  ACTION:  against  parents,  83-86 

LEGAL  PROVISIONS:  regarding  dental 
clinics,  124.  See  also  Legislation; 
Laws 

LEGISLATION,  MEDICAL  INSPECTION: 
endorsed  by  boards  of  health  in 
conference,  173;  in  different  coun- 
tries of  Europe  and  the  United 
States,  7-13.  See  Laws,  Medical 
Inspection;  Regulations;  Education 
Act 

LEICESTER,  England:  treatments  in,  99 
LINCOLN:    England:    treatments  in,  99 

LOME,  HENRY:  gift  by,  to  establish 
dental  clinic  in  Rochester,  120,  121 

LONDON:  medical  inspection  in,  10; 
school  nurses  in,  n,  62 

Los  ANGELES:  resolutions  adopted  by 
boards  of  health  in  meeting  at,  173 

LOUISIANA:  medical  inspection  regula- 
tions in,  164,  168 

LOWELL,  Massachusetts:  treatments 
following  examinations  by  teachers 
in,  97 

LUNGS:  examined  in  medical  inspection, 
9,  37.  See  also  Pulmonary  Dis- 
ease 

LYNN,  Massachusetts:  charges  of  dental 
dispensary  in,  127 


MAINE:  abstract  of  medical  inspection 
law,  1 68;  vision  and  hearing  tests 
prescribed  in,  101;  vision  and  hear- 
ing tests,  results,  52 

MAINTENANCE:  cost  of,  for  dental 
clinics  in  Germany,  126 

MALAYS:  teeth  of,  116 


MALNUTRITION:  among  school  children 
in  New  York,  40;  treated  in  Harris- 
burg,  Penn.,  94;  treated  in  New 
York,  92.  See  also  Nutrition 

MANCHESTER.     See  South  Manchester 
MANITOBA:    medical  inspection  in,  12 
MARTIN,  GEORGE  H.:  quoted,  150 

MASSACHUSETTS:  appointment  of  medi- 
cal inspectors  in,  150;  Board  of 
Health,  directions  as  to  methods 
of  testing  vision  and  hearing, 
quoted,  45,  46,  47;  forms  used 
in  connection  with  vision  and 
hearing  tests  in,  48,  50;  history  of 
medical  inspection  legislation  in, 
13;  instructions  regarding  symp- 
toms of  contagious  diseases  issued 
in,  30;  methods,  typical  of  practice 
in  other  states,  51;  notice  to 
parent  used  in,  72,  73;  results  of 
vision  and  hearing  tests  in,  51,  52; 
tests  by  teachers  in,  influence  of, 
44,  101 

MASSACHUSETTS  MEDICAL  INSPECTION 
LAW:  abstract  of,  168;  and  Eng- 
lish Act,  most  important,  174; 
examinations  required  by,  no; 
mandatory,  4,  164;  provisions  re- 
garding school  children  returning 
after  illness,  21;  similarities  to 
English  Act,  179,  180;  text  of,  178 

MAXWELL,  WILLIAM  H.:  quoted,  145 
MEASLES:  exclusions  for,  30-33 

MEDICAL  ASSOCIATION,  BRITISH:  salary 
standard  for  medical  inspection 
established  by,  109 

MEDICAL  ASSOCIATIONS,  LOCAL:  con- 
duct medical  inspection,  108 

MEDICAL  INSPECTION:  administration 
in  cities  of  United  States,  143-151; 
administration  in  England,  176; 
four  features  of,  19,  20;  forms  of 
records  used  in,  21-27,  48,  50,  52- 
58,  _  73~75>  77-79,  134-142;  per 
capita  cost  for,  102-110;  results 
should  be  stated  with  moderation, 
40;  statistical  statements  of  re- 
sults rare,  89;  status  of,  in  cities  of 
United  States,  15-20;  treatments 
resulting  from,  91-100.  See  also 
Examinations  ;  Contagious  Diseases; 
names  of  countries  and  cities 


2l6 


INDEX 


MEDICAL  INSPECTORS.  See  Physicians, 
School;  Inspectors 

MEDICAL  OFFICER,  CHIEF:  English 
Board  of  Education,  quoted,  98 

MEDICAL  SOCIETY  OF  NEW  JERSEY: 
quotation  from  journal  of,  87 

MEDICAL  TREATMENTS:  in  New  York, 
92,  96.  See  also  Treatments;  names 
of  cities 

MEMORANDUM:  English  board  of  edu- 
cation, provisions  of,  10,  41,  175, 
176 

MENTAL  DEFECTS:  among  exempt  and 
non-exempt  children  in  Philadel- 
phia, 153 

MEXICO:  medical  inspection  in,  12 

MIDDLESBOROUGH,  England:  treat- 
ments in,  99 

MIDDLESEX,  England:  treatments  in, 
99 

MILWAUKEE,  Wisconsin:  woman  den- 
tal inspector  in,  122 

MINNESOTA:  regulations  on  medical 
inspection  in,  164,  169;  vision  and 
hearing  tests  prescribed  in,  102 

MONTREAL:  school  physicians  ap- 
pointed in,  12 

MORLEY,  England:  treatments  in,  99 

MOUTH  HYGIENE:  instruction  in,  by 
nurses,  91 

MULHAUSEN:  dental  work  in,  126 
MUMPS:  exclusions  for,  31-33 

MUNICIPAL  INSURANCE  COMMITTEE  of 
Hamburg  dental  clinic,  117 

MUSKEGON,  Michigan:  cost  of  equip- 
ment for  dental  clinic  in,  125; 
dental  work  in,  88,  123 

NASAL  BREATHING:  prevented  by 
adenoids,  4.  See  Breathing,  Defec- 
tive 

NERVOUS  SYSTEM,  defects  of:  looked 
for  in  medical  inspection,  37; 
treated  in  Pasadena,  94.  See  also 
Chorea 

NEWARK,  N.  J.:  children  treated  free 
in  dental  clinic,  126;  exclusions 


NEWARK,  N.  J.  (Continued) 

for  contagious  diseases  in,  32,  33; 
four  physical  defects  treated  in, 
93;  number  of  pupils  examined  in, 
1910-11,  41;  results  of  physical 
examinations  in,  38;  rules  for 
nurses  in,  68;  staff  and  salaries  in 
dental  clinics  of,  127;  supervisor 
of  medical  inspection  in,  quoted,  87 

NEW  JERSEY:  law  regarding  dental 
clinics  in,  124;  medical  inspec- 
tion legislation  in,  13,  164,  169; 
provision  for  compulsory  action 
against  parents  in,  85 

NEW  JERSEY  AND  CALIFORNIA:  highest 
costs  for  salaries  in  cities  of,  103 

NEWMAYER,  SAMUEL  W.:  data  pre- 
sented by,  to  prove  effectiveness 
of  nurses'  work,  66,  67;  investi- 
gation of  defects  among  school 
children  by,  153 

NEW  YORK  CITY:  beginning  of  medical 
inspection  in,  13;  Children's  Aid 
Society  issues  directions  regarding 
teeth,  129,  sells  tooth  brushes,  129; 
dental  clinics,  121,  122,  125;  ex- 
clusions for  contagious  diseases, 
32,  33;  funds  wasted  in  attempting 
education  of  defective  children, 
162;  number  of  pupils  examined 
in  1911, 41 ;  origin  of  school  nursing, 
63;  records  of  defects  treated  in, 
91,  92;  reduction  of  exclusions 
after  introduction  of  school  nursing, 
63,  65 ;  results  of  physical  examina- 
tions in,  38,  40;  study  of  retarda- 
tion in  public  schools  of,  156-163; 
treatments  by  private  practi- 
tioners and  institutions  in,  96 

NEW  YORK  STATE:  abstract  of  medical 
inspection  law,  169;  board  of 
health  employs  dentists  to  lecture, 
127 

Nineteenth  Century :  article  in,  referred 
to,  116 

NORFOLK,  England:  treatments  in,  99 

NORMAL  SCHOOLS:  provision  regarding, 
in  new  laws,  172 

NORTHAMPTON,  England:  salaries  of 
medical  inspectors  in,  no 


217 


INDEX 


NORTH  DAKOTA:  abstract  of  medical 
inspection  law  in,  169 

NORWAY:  dental  conditions  among 
school  children  in,  115;  medical 
inspection  in,  1 1 

NOSE,  DEFECTS  or:  among  exempt  and 
non-exempt  children,  153;  im- 
portance among  school  children, 
35;  number  of  children  having,  in 
different  cities,  38;  one  of  four 
commonest  classes  of  defects,  37, 
39;  treated  in  Pasadena,  94.  See 
also  Breathing;  Adenoids 

NOSE  TROUBLES:  health  pamphlet  on, 
80 

NOTICE  of  results  of  vision  and  hearing 
tests  used  in  Massachusetts,  50 

NOTIFICATION  TO  PARENTS:  form  used 
for,  73;  not  always  sufficient  to  se- 
cure action,  72,  88 

NOTTINGHAMSHIRE,  England:  treat- 
ments in,  99 

NURSES,  SCHOOL:  and  school  clinics,  87; 
average  per  capita  cost  for  medical 
inspection  in^cities  employing,  103; 
cannot  meet  situation  alone,  86; 
duties  of,  64,  71;  effectiveness  of 
work  of,  34,  65-67;  employment  of, 
advised  by  English  board  of  edu- 
cation, 177;  equipment  for,  112; 
follow  up  visits  to  secure  action,  76; 
in  Germany,  10;  in  London,  n; 
in  United  States,  by  groups  of 
states,  18,  20;  in  United  States, 
number  employed,  63;  instruc- 
tions in  mouth  hygiene  given  by, 
La  New  York,  91;  proportion  of 
children  to,  68;  provision  for,  in 
new  laws,  172;  qualifications  of, 
64;  record  results  of  examination, 
43;  rules  for,  in  Newark,  N.  J.,  68; 
salaries,  70,  71,  102-108;  under 
school  supervision,  146;  work  of, 
in  contagious  disease  cases,  30; 
value  of,  unquestioned,  62 

NURSING,  SCHOOL:  history  of,  62 

NUTRITION,  DEFECTIVE:  looked  for  in 
medical  inspection,  37;  treated  in 
Pasadena,  94.  See  also  Malnu- 
trition 


OAKLAND,  California:  consultations 
with  director  of  health  develop- 
ment in,  77,  79;  number  of  pupils 
examined  in,  1910-11,  41,  42; 
results  of  physical  examinations 
in,  38;  treatments  of  defective 
children  in,  96 

OCULIST,  SCHOOL:  early  work  of,  in 
Belgium,  n 

OHIO:  abstract  of  medical  inspection 
law  of,  170 

ONTARIO:   medical  inspection  in,  12 

OPEN-AIR  SCHOOLS:  establishment  of, 
desirable,  98;  in  Germany,  10 

OPERATIVE  TREATMENTS:  in  Newark, 
93;  in  New  York,  92,  96.  See 
also  Treatments;  Defects 

ORTHOPEDIC  DEFECTS:  among  exempt 
and  non-exempt  children  in  Phila- 
delphia, 153;  among  school  chil- 
dren in  New  York,  40;  treated  in 
New  York,  92 

OSLER,  WILLIAM:  quoted,  viii,  103,  114 

OVER-AGE  CHILDREN:  defects  among, 
compared  with  those  among  nor- 
mal, 154.  See  Retardation 


PALATES,  DEFECTIVE:  among  school 
children  in  New  York,  40;  treated 
in  New  York,  92 

PALATES,  DEFORMED  :  treated  in  Harris- 
burg,  94 

PARASITIC  DISEASES:  detection  and 
exclusion  of,  21 

PARENTS  OF  SCHOOL  CHILDREN:  com- 
pulsory action  against,  83-86; 
English  medical  inspection  act 
has  no  provision  for  compulsory 
action  against,  177;  imprisoned 
and  fined  in  England,  86;  instruc- 
tion by  printed  bulletins,  80;  left 
with  larger  responsibility  by  medi- 
cal inspection,  5;  means  of  securing 
co-operation  of,  72-79,  177;  new 
laws  should  provide  for  notification 
of,  172;  notified  in  Paris,  8;  noti- 
fied in  Wiesbaden,  9;  payments  by, 
for  dental  treatment,  in  Germany, 
117,  118;  poverty  of,  creates  prob- 


218 


INDEX 


PARENTS  OF  SCHOOL  CHILDREN  (Con- 
tinued) 

lem,  86,  88;  presence  of,  at  ex- 
aminations, 73,  75,  76;  right  to 
insist  that  child  in  school  shall  be 
safe,  4 

PARIS:  medical  inspection  in,  7,  8 

PASADENA,  California:  consultations 
with  medical  examiner  in,  77,  78; 
number  of  pupils  examined  in, 
1909-10,  41;  record  of  physical 
examinations  used  in,  53,  55;  re- 
sults of  physical  examinations  in, 
38;  treatments  in,  94 

PAYMENTS:  for  dental  treatment,  by 
parents  in  Germany,  117,118.  See 
Salaries 

PEDICULOSIS:  directions  and  prescrip- 
tion for,  27,  28;  exclusions  for, 
30-33 

PENCE,  England:  treatments  in,  99 

PENNSYLVANIA:  abstract  of  medical 
inspection  law  of,  170 

PENSIONS  FOR  SCHOOL  PHYSICIANS,  9 

PER  CAPITA  COST:  for  dental  treat- 
ment of  school  children,  125-127; 
for  salaries  of  inspectors  and  nurses, 
102-107.  See  also  Cost 

PHILADELPHIA:  beginning  of  medical 
inspection  in,  13;  data  on  effective- 
ness of  nurses'  work  in,  66,  67; 
defective  exempt  and  non-exempt 
children  in,  152,  153;  dental  work 
in,  88,  123;  directions  and  prescrip- 
tion for  tooth  powder  in,  128;  ex- 
clusions and  school  membership 
in,  33;  salaries  of  school  dentists 
in,  127;  supplies  and  equipment 
for  dental  clinic  in,  125 

PHYSICAL  CULTURE  TREATMENTS  IN 
NEW  YORK,  96 

PHYSICAL  EXAMINATIONS.  See  Ex- 
aminations 

PHYSICIANS,  PRIVATE:  treatments  by, 
New  York,  96;  treatments  by, 
St.  Louis,  97 

PHYSICIANS,  SCHOOL:  and  school 
clinics,  87;  conduct  of  physical 
examinations  by,  3.7;  contagious 
disease  work  of,  21,  30;  equipment 
for,  in;  examinations  by,  in 


PHYSICIANS,  SCHOOL  (Continued) 

cities  of  United  States,  19,  20; 
four  possible  functions  of,  89,  90; 
forbidden  to  make  suggestions  as 
to  treatment,  31;  have  varying 
standards,  39;  in  Belgium,  n;  in 
Boston,  13;  in  Cairo,  12;  in 
France,  7;  in  Hungary,  12;  in 
London,  10;  in  Montreal,  12;  in 
New  York  City,  13;  in  Sweden,  n; 
in  Switzerland,  12;  in  United 
States,  1 6, 17,  20;  in  Wiesbaden,  9; 
inspections  placed  in  hands  of,  by 
state  laws,  165;  office  consultations 
with,  76,  77,  78,  79;  report  of, 
features  desirable  in,  90;  salaries 
in  England,  109-110;  salaries  in 
Germany,  9;  salaries  in  United 
States,  102-110;  section  of  Massa- 
chusetts law  on,  178;  tests  of 
vision  and  hearing  made  by,  in 
cities  of  United  States,  51;  time 
taken  by  clerical  work,  24,  no, 
in,  113.  See  also  Inspectors 

POLAND,  DR.:  quotation  from,  on 
medical  inspection  under  board 
of  health,  147 

PREMISES,  SCHOOL:  provision  for  in- 
spection of,  in  new  laws,  172 

PROGRESS,  SCHOOL:  and  physical  de- 
fects, 152-163 

PROMOTED  AND  NON-PROMOTED  CHIL- 
DREN: defects  among,  in  South 
Manchester,  155 

PROMOTION:  normal  and  retarded 
children  who  failed  of,  in  Camden, 
154 

PROVISIONS  which  new  medical  inspec- 
tion laws  should  include,  171,  172 

PRUSSIA:  dental  conditions  among 
school  children  in,  115 

Psychological  Clinic:  article  in,  152 

PUBLIC  HEALTH  ASSOCIATION  of  Roch- 
ester: supplied  premises  for  clinic, 
1 20 

PUBLIC  SCHOOLS:  a  public  trust,  4.  See 
Buildings;  Premises 

PULMONARY  DISEASE:  among  school 
children  in  New  York,  40;  treated 
in  Harrisburg,  Penn.,  94;  treated 
in  New  York,  92.  See  also  Lungs 


219 


INDEX 


PUPILS:  enrolled  and  examined,  in 
nine  cities,  41;  found  defective  in 
vision  and  hearing,  52;  proportion 
of  nurses  to,  68.  See  also  Children 


RACHITIS:  among  retarded  children  in 
Elmira,  156 

RATE,  PER  CAPITA:  for  efficient  medical 
inspection,  103.  See  also  Cost 

READING,  Pennsylvania:  dental  clinics 
in,  121,  122,  125 

RECORDS,  FORMS,  AND  BLANKS  used  in 
medical  inspection,  21-27,  48,  50, 
52-58,  73-75,  77-79,  134-142. 
See  List  of  Forms,  p.  xix 

RECORDS:  individual,  should  follow 
children,  53;  making  entries  on, 
consumes  inspectors'  time,  24,  no, 
in,  113;  of  combinations  of  de- 
fects, 58-61;  of  physical  examina- 
tions in  Paris,  8;  in  Wiesbaden 
system,  9;  of  physical  examina- 
tions, three  essential  classes  of, 
52,  58;  used  in  connection  with 
vision  and  hearing  tests  in  Massa- 
chusetts, 48,  50 

REGULATIONS:  on  medical  inspection, 
states  having,  164.  See  Laws 

REPORTS  OF  SCHOOL  PHYSICIANS: 
features  they  might  contain,  90, 
91;  rarity  of  statistical  statements 
of  results  in,  89 

REPORTS.    See  List  of  Forms,  p.  xix 

RESOLUTIONS:  adopted  at  conference 
of  boards  of  health,  173 

RESULTS  OF  MEDICAL  INSPECTION: 
features  desirable  in  reports  on, 
90,  91;  records  of  treatments,  91- 
100;  should  be  stated  with  modera- 
tion, 40;  statistics  on,  rare,  89 

RETARDATION  AND  DEFECTIVENESS  : 
conclusions  reached  on,  tentative, 
163;  study  in  Camden,  154-155; 
study  in  Elmira,  155-156;  study 
in  New  York,  156-163 

RETARDED  CHILDREN.  See  Retarda- 
tion 


RHODE  ISLAND:  abstract  of  medical 
inspection  law  of,  170;  vision  and 
hearing  tests  prescribed  in,  102 

RINGWORM:  directions  and  prescrip- 
tion for,  27,  29;  exclusions  for, 
30,  32,  33 

ROCHESTER,  New  York:  dental  clinics 
in,  88,  114,  120;  equipment  of 
dental  clinic  in,  125;  exclusions  and 
school  membership  in,  33;  lecturer 
to  children  secured  by  dental  as- 
sociation in,  128;  number  of  pupils 
examined  in,  1910,  41;  per  capita 
cost  for  dental  treatment  in,  126; 
results  of  physical  examinations  in, 
38;  salaries  of  school  dentists  in, 
127 

ROGERS,  LINA  L. :  first  school  nurse  in 
America,  63 

ROMAN  SOLDIERS:  jaws  of,  compared 
with  those  of  British  soldiers,  116 

ROSE,  KARL:  on  teeth  of  different 
peoples,  116 

ROUMANIA:    me.dical  inspection  in,  12 
RULES  FOR  NURSES:  Newark,  N.  J.,  68 

RUSSELL  SAGE  FOUNDATION:  investiga- 
tion regarding  medical  inspection 
conducted  by,  14,  36,  63,  103; 
study  of  retardation  by,  156 

RUSSIA:  dental  clinics  in,  120;  medical 
inspection  in,  1 1 


ST.  Louis,  Missouri:  concentration  of 
examinations  on  19  schools  in,  42; 
number  of  pupils  examined  in, 
1910-11,  41;  parents'  consent 
blank  used  in,  73,  75;  results  of 
physical  examinations  in,  38;  treat- 
ments of  defective  children  in,  96; 
treatments  by  family  physicians 
and  institutions  in,  97 

ST.  PETERSBURG:  dental  clinics  in,  120 

SALARIES:  and  per  capita  cost,  102-110; 
of  school  dentists  in  clinics,  127; 
of  school  dentists  in  Somerset, 
England,  119;  of  school  nurses  in 
cities  of  United  States,  70,  71, 
102-108;  of  school  physicians  in 
cities  of  United  States,  102-109; 
of  school  physicians  in  England, 


22O 


INDEX 


SALARIES  (Continued) 

109,  no;    of  school  physicians  in 
Germany,  9 

SALISBURY,  Eng. :  treatments  in,  99 
SANITARY  INSPECTION:  in  France,  7 

SAN  Luis  PoTosf:  medical  inspection 
in,  12 

SAXE-MEININGEN:  medical  inspection 
in,  9 

SCABIES:  directions  and  prescription 
for,  27,  29;  exclusions  for,  31-33 

SCALP,  DISEASES  OF:  treated  in  English 
clinics,  87 

SCARLET  FEVER:   exclusions  for,  30-33 
SCHONEBERG:  dental  work  in,  126 

SCHOOL  AUTHORITIES:  administration 
of  medical  inspection  by,  164 

SCHOOL  CLINICS.    See  Clinics 
SCHOOL  FEEDING:  in  Germany,  10 

SCHOOL  MEMBERSHIP:  and  exclusions, 
in  eight  cities,  33.  See  also  En- 
rollment 

SCHOOL  NURSES'  SOCIETY  formed  in 
London,  62 

SCHOOL  PROGRESS:  and  physical  de- 
fects, 152-163 

SCHOOLS:  closing  of,  because  of  epi- 
demics, 34 

SCHOOLS,  OPEN-AIR:  establishment  de- 
sirable, 98 

SCOTLAND:  dental  work  in,  120;  medi- 
cal inspection  in,  10 

SENSE  ORGANS:  examined  in  Wies- 
baden, 9.  See  Eye;  Ear;  Nose; 
Sight;  Hearing;  Vision 

SHEPHERD,  FRED  S.:   quoted,  147,  148 

SIGHT  AND  HEARING,  DEFECTIVE:  as 
handicaps  in  school  work,  3,  4. 
See  Ears;  Eyes;  Hearing;  Vision 

SKIN:  examined  in  Wiesbaden,  9 

SKIN  DISEASES:  among  exempt  and 
non-exempt  children  in  Phila- 
delphia, 153;  treated  in  English 
communities,  87,  99;  treated  in 
Harrisburg,  Penn.,  94.  See  also 
Impetigo;  Ringworm;  Scabies 


SMALL-POX:  exclusions  for,  30,  31 

SNELLEN  CHART:  used  in  Massa- 
chusetts, 47;  reproduced,  49 

SOMERSET  COUNTY:  allowance  for 
materials  for  dental  work  in,  126; 
rate  of  payment  to  school  dentists 
in,  127;  school  dental  work  in,  119 

SOMERVILLE,  Massachusetts:  treat- 
ments following  examinations  by 
teachers  in,  97 

SOUTH  AMERICA:  medical  inspection 
in,  12 

SOUTH  MANCHESTER,  Connecticut: 
study  of  defective  children  in, 
155;  teeth  of  school  children  in, 
117  , 

SOUTH  SHIELDS,  England:  treatments 
in,  99 

SPINE:  examined  in  Wiesbaden,  9. 
See  Orthopedic  Defects 

SPOKANE,  Washington:  exclusions  in, 
144 

SPRINGFIELD,  Massachusetts:  superin- 
tendent of  schools,  quoted,  150 

STAFFORD,  England:  salaries  of  medical 
inspectors  in,  no 

STATE:  duties  and  rights  of,  in  medical 
inspection,  4,  5 

STATE  REGULATIONS:  in  Germany,  9; 
in  Norway,  u.  See  Regulations; 
Laws 

STATISTICS:  showing  results  of  medical 
inspection  rare,  89 

STRASSBURG:  dental  clinic  in,  117,  118; 
salaries  of  school  dentists  in,  127; 
dental  work  in,  126 

STUTTGART:  school  nurses  in,  10;  dental 
work  in,  126 

SUMMIT,  New  Jersey:  defects  treated 
in,  95 

SUPPLIES:  and  equipment  for  dental 
clinics,  125;  for  school  nurses,  112 

SURREY,  England:  treatments  in,  99 
SUSSEX:  treatments  in,  99 
SWEDEN:  medical  inspection  in,  u 


221 


INDEX 


SWITZERLAND:    dental  clinics  in,   120; 
medical  inspection  in,  n,  12 

SYMPTOMS  OF  DISEASE:  which  teachers 
should  notice,  30 

SYRACUSE,  New  York:   use  of  colored 
forms  in,  27 


TASMANIA:  medical  inspection  in,  12 

TEACHERS:  duties  of,  in  medical 
inspection  in  Colorado,  84,  85; 
examinations  of,  provision  for,  in 
state  laws,  164,  172;  opinions  as 
to  ability  to  test  vision  and  hearing, 
44,  45;  plan  of  having  physical 
records  made  by,  43;  practicability 
of  tests  by,  demonstrated,  51; 
record  height  and  weight,  Wies- 
baden system,  9;  treatments 
following  examinations  by,  97; 
work  of,  in  detection  of  contagious 
disease,  21,  27,  30.  See  also 
Vision  and  Hearing  Tests 

TEETH:  directions  for  care  of,  issued 
by  Children's  Aid  Society  of  New 
York,  129;  leaflet  on  care  of, 
issued  in  Waltham,  Massachusetts, 
131;  pamphlet  on,  by  Dr.  Hoag, 
132 

TEETH,  DEFECTIVE:  among  children 
promoted  and  not  promoted  in 
South  Manchester,  155;  among 
different  peoples,  116;  among 
school  children  in  different  cities, 
38;  among  school  children  in 
different  countries,  114, 115;  among 
school  children  in  New  York,  40; 
and  school  progress  in  New  York, 
158-162;  early  discovery  of,  im- 
portant, 35;  extractions  and  fillings 
among  school  children  in  New 
York,  92, 96 ;  handicap  imposed  by, 
in  terms  of  retardation,  162;  in 
children  with  adenoids  and  enlarged 
tonsils,  58;  instruction  in  mouth 
hygiene  by  nurses  in  New  York,  91 ; 
one  of  four  commonest  classes 
of  defects,  37,  39;  physical  deter- 
ioration caused  by,  114;  treated  in 
English  school  clinics,  87;  treated 
in  Newark,  N.  J.,  93;  treated  in 
New  York,  92;  treated  in  Pasadena, 
Cal.,  94;  treated  in  Summit,  N.  J., 
95 


THROAT,  DEFECTS  OF:  among  children 
in  different  cities,  38;  among 
exempt  and  non-exempt  children, 
153;  early  discovery  of  important, 
35;  one  of  four  commonest  classes 
of  defects,  37,  39;  treated  in 
Pasadena,  Cal.,  94 

THROATS:  examined  in  Wiesbaden,  9; 
treated  in  English  school  clinics,  87 

THROAT  TROUBLES:  health  pamphlet 
on,  80 

TIME  and  cost  of  physical  examinations, 
43 

TIME  necessary  for  vision  and  hearing 
tests,  102 

TONSILITIS:  exclusions  for,  130-133 

TONSILS,  HYPERTROPHIED:  among  re- 
tarded children  in  Elmira,  156; 
among  New  York  school  children, 
40;  and  associated  defects,  58; 
and  school  progress  in  New  York, 
158-162;  handicap  imposed  by, 
in  terms  of  retardation,  162; 
how  classified,  39;  treated  in 
English  communities,  99;  treated 
in  Harrisburg,  94;  treated  in 
Newark,  N.  J.,  93;  treated  in  New 
York,  92;  treated  in  Summit,  95 

TOOTH  BRUSHES:  and  powder  given  to 
children  in  Philadelphia  dental 
clinic,  128;  sold  to  children  by 
Children's  Aid  Society  of  New 
York,  129;  supplied  to  patients  in 
Strassburg  clinic,  117 

TRACHOMA:  exclusions  for,  30 

TREATMENT,  DENTAL:  in  Strassburg 
clinic,  117 

TREATMENT  OF  CHILDREN:  securing 
parents'  consent  to,  73 

TREATMENTS  FOR  PHYSICAL  DEFECT: 
in  cities  of  the  United  States,  91-98; 
in  English  communities,  98-100 

TRENTON,  New  Jersey:  treatments  of 
defective  children  in,  96 

TUBERCULOUS  CHILDREN:  open  air 
schools  for,  98 


222 


INDEX 


TUBERCULOUS  LYMPH  NODES:  among 
school  children  in  New  York,  40; 
treated  in  New  York,  92 


UNGHAVARI:  studies  in  dental  condi- 
tions, results  of ,  114 

UNITED  STATES:  administration  of 
systems  of  medical  inspection  in, 
145;  census  bureau's  grouping 
of  states,  14;  cities  of,  employing 
school  dentists,  19;  cities  of,  em- 
ploying school  nurses,  18;  cities  of, 
employing  school  physicians,  17; 
cities  of,  having  medical  inspection, 
15,  16,  17;  cities  of,  having  exami- 
nations for  physical  defects,  36; 
dental  work  for  school  children  in, 
114,  120-142;  development  and 
present  status  of  medical  inspec- 
tion in,  1911,  13-20;  treatment 
of  defects  in,  compared  with  that 
in  England,  100 

UNITED  STATES  COMMISSIONER  OF 
EDUCATION:  figures  from  reports 
of,  34,  42,  103 

UTAH:  abstract  of  medical  inspection 
law  of,  170;  vision  and  hearing 
tests  prescribed  in,  102 

UTICA,  New  York:  use  of  colored  forms 
in,  27 


VALPARAISO,  Indiana:  dental  work  in, 
123,  128 

VANCOUVER:    medical  inspection  in,  12 

VERMIN  AND  SKIN  DISEASES:  forms 
used  in  cases  of,  27,  28,  29.  See 
also  Pediculosis 

VERMONT:  abstract  of  medical  inspec- 
tion law  of,  170;  medical  inspec- 
tion legislation  in,  13 

VERPLANCK,  FRED.  A.:  report  on  teeth 
of  school  children  by,  117;  study 
of  defective  children  by,  155 

VIRGINIA:  abstract  of  medical  inspec- 
tion law  of,  171;  State  board  of 
health,  bulletin  on  teeth  issued  by, 
127 


VISION  AND  HEARING  TESTS:  by  teach- 
ers, cost  of,  101,  102,  112;  by 
teachers,  do  not  take  place  of 
thorough  examination,  102;  by 
physicians  and  teachers  in  cities 
of  United  States,  20,  51,  52; 
directions  for  making,  issued  by 
Massachusetts  Board  of  Health, 
45-47;  forms  used  in  Massachu- 
setts, 48,  50;  opinions  of  special- 
ists as  to  teachers'  ability  to  make, 
44,  45;  new  laws  should  provide 
for,  172;  provision  for  in  state 
laws,  101, 165;  results  of,  in  Massa- 
chusetts, Connecticut,  and  Maine, 
52;  section  of  Massachusetts  law 
on,  179;  time  necessary  to  conduct, 
102;  treatments  following,  in 
Lowell  and  Somerville,  Mass.,  97 

VISION,  DEFECTIVE:  among  children 
in  New  York  schools,  40;  among 
exempt  and  non-exempt  children 
in  Philadelphia,  153;  among  nor- 
mal and  retarded  children  in 
Camden,  154;  among  retarded  chil- 
dren in  Elmira,  156;  and  school 
progress  in  New  York,  158-161, 163; 
effect  of,  on  children,  35;  increases 
with  age,  157,  158;  percentage  of 
children  suffering  from,  35;  treated 
in  English  communities,  99;  treated 
in  Harrisburg,  Penn.,  94;  treated 
in  Newark,  N.  J.,  93,  in  New  York, 
92;  treated  in  Summit,  95.  See 
also  Eyes;  Eyesight 

VISITS  TO  HOMES:  made  by  nurses,  76 


WALD,  LILLIAN  D.:    lent  services  of 
nurse  for  school  work,  63 

WALES  :  dental  inspection  under  way  in , 
120;  medical  inspection  in,  10 

WALKER,    D.    HAROLD:     opinion    on 
teachers'  ability  to  test  hearing,  45 

WALTHAM,  Massachusetts:    leaflet  on 
care  of  teeth  issued  in,  131 

WASHINGTON:  abstract  of  medical  in- 
spection law  of,  171 

WATER,  DRINKING:    provision  for  in- 
spection of,  in  new  laws,  172 


223 


INDEX 


WEIGHT  AND  HEIGHT,  RECORDS  or: 
futile,  37;  in  Paris,  8;  in  Wiesbaden 
system,  9 

WEST  VIRGINIA:  abstract  of  medical 
inspection  law  of,  171 

WHOOPING  GOUGH:  exclusions  for,  31- 
33 


WIESBADEN: 
8-9 


medical    inspection    in, 


WINCHESTER,  Massachusetts:  rates  for 
dental  treatment  of  school  children 
in, 127 

WOLVERHAMPTON, 

ments  in,  99 


WORCESTERSHIRE  , 
ments  in,  99 


England:       treat- 
England:       treat- 


YORKS  (East  Riding),  England:    treat- 
ments in,  99 


224 


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